Appointing/designating a representative
At some point, you may want or need to have someone act on your behalf when it comes to making decisions for you. This person can be a spouse, family member, friend, caregiver, advocate, attorney, financial advisor, doctor, or someone else. You cannot choose a law firm or group to act as your representative.
Why appoint a representative?
When you appoint someone as your representative, she/he can help you with filing a coverage determination, appeal, or grievance.
How to Appoint a Representative
To appoint someone as your representative, you and your representative must complete, date, and sign an Appointment of Representative form (CMS-1696). You can send us your completed, dated, and signed form by:
- Mailing to Arkansas Blue Medicare P.O. Box 3648 Little Rock, AR 72203
- Emailing to [email protected]
Forms
For how long is a signed Appointment of Representative valid?
An Appointment of Representative is valid for one year from the date the form is signed by both you and your representative. Also, the Appointment of Representative is valid for the duration of an appeal (when you file one). If you want to continue your Appointment of Representative at the end of the year, you and your representative will need to complete, date, sign, and submit a new form.
What if I decide to end my Appointment of Representative?
If you decide to revoke or end your current Appointment of Representative, you must tell us in writing. Send a written, dated, and signed statement. It should tell us you want to revoke your Appointment of Representative. Send your statement to: Arkansas Blue Medicare P.O. Box 3648 Little Rock, AR 72203.
Important
- If your appointed representative is an attorney, only you need to sign the Appointment of Representative.
- A request for a coverage determination or re-determination from your appointed representative is not valid until we receive a signed Appointment of Representative.
Return to top