Appointment of Representatives

An enrollee may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as his or her representative. A representative who is appointed by the court or who is acting in accordance with State law may also file an appeal for an enrollee. With the exception of incapacitated or legally incompetent enrollees where appropriate legal papers, or other legal authority support this representation, both the enrollee making the appointment and the representative accepting the appointment must sign, date, and complete an Appointment of Representative form (.pdf) or similar written statement. If the appointed representative is an attorney, only the enrollee needs to sign the Appointment of Representative form or similar statement.

The representative statement must include the enrollee's name and Medicare number. The enrollee may use Form CMS-1696-U4 (see below) or SSA-1696-U4, Appointment of Representative (available at Social Security offices), although it is not required.

• Appointment of Representative Form (.pdf)
• In Spanish: Nombramiento de Representativo, Formulario (.pdf)

Last Updated: 6-14-11
H5703_1747, H2419_1747, CMS Approved 7-31-2011
H2419_1736, H5703_1736, CMS Approved 7-30-2011
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South Country Health Alliance is a Coordinated Care plan with a Medicare Advantage
contract and a contract with the Minnesota Medical Assistance program.