You are here

How to Appoint a Representative

As a Medicare enrollee, you have the right to ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.

  • There may be someone who is already legally authorized to act as your representative under State law.
  • If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services and request for the “Appointment of Representative” form. The form is also available on Medicare’s website or by clicking on the attachments below. The form allows you to give a person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give the plan a copy of the signed form.
  • You may also contact your local Social Security Office or get help from your local Agency on Aging office.

The appointment is considered valid for one (1) year from the date that the “Appointment of Representative Form” is signed by you (the member) and your legal representative. Also, the representation is valid for the duration of a grievance, a request for organization determination, or an appeal in which it was received with. 

Appointment of Representative

For instructions and access to the CMS Appointment of Representation Form (Form CMS-1696), click on the link below:

Once you or your authorized representative have completed and signed the “Appointment of Representative” form you may mail or send via fax to:

Simply Healthcare Plans
Attn: Member Services Department
9250 W. Flagler Street, Suite 600
Miami, FL 33174-3460
Call: 1-877-577-0115 (TTY 711)
Fax number: 1-877-577-0114
Last Updated: 
November 27, 2017