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How can I name someone to act on my behalf?

Who is this for?

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If you want to let someone represent you in a Medicare appeal or grievance, use this form.

Do you need someone to file a complaint or appeal for you? If so, this document allows you to name someone to make decisions for you. This person is often a relative, friend, lawyer or doctor.

What you'll need to do.

  1. Make sure you have your Medicare number. Print or type your number and your name on the top of the form.
  2. Appoint at least one person to act on your behalf. You can name more than one. If you do, you may want to complete a form for each of them.
  3. You can appoint a spouse, family member, friend, lawyer or caregiver. You must name individual people. You can't name a law firm, legal aid group or organization to represent you. It has to be a person. 
  4. Each person you appoint needs to complete the Acceptance of Appointment section. They provide their names and state where they accept the appointment.
  5. The person or people you name should fill out the Waiver of Fee for Representation part of the form if he or she won't charge you for acting on your behalf.
Tip: A Durable Power of Attorney agreement can work in place of an Appointment of Representative form. That means you don't have to fill out an Appointment of Representative form if they have a Durable Power of Attorney agreement in place. The latter covers all of their care decisions.

Here's the form you'll need: