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Appointment of Representative Form

Who is this for?

Find forms here.

If you want to appoint someone as your legal representative for Medicare coverage requests and appeals, you can download the required form and get instructions here.

When you’re focused on your health, you may need help with everyday affairs.

So you may choose to have a relative, friend, attorney, physician or other advocate serve as your Medicare representative.

But, first, you and your representative need to download and fill out an Appointment of Representative form (PDF). The following instructions explain what to do.

How to complete this form

Please print or type. At the top, provide your full name and Medicare number. If you appoint more than one person, you’ll need to fill out a form for each of them.

  • Section 1: Appointment of Representative: Give the name and address of the person you’re appointing. You may list one or more persons in an organization, but not the organization itself. Sign and date this section as the “Party Seeking Representation” and provide your street address and phone number.
  • Section 2: Acceptance of Appointment: Your representative fills out this section. He or she must give his or her name, sign and date the form, and provide his or her street address and phone number.
  • Section 3: Waiver of Fee for Representation: Completing this portion of the form means your representative won't charge a fee to represent you. If your representative is a health care provider, he or she is required to list your name, sign and date this section.  
  • Section 4: Waiver of Payment for Items or Services at Issue: If your representative is a health care provider, he or she must sign and date this section. Doing so means you won’t be billed for items or services your plan doesn’t cover if they’re submitted on your behalf.

Where to send this form

If your representative will represent you in medical matters with Blue Cross Blue Shield of Michigan, mail the form to:

     Blue Cross Blue Shield of Michigan
     Grievances and Appeals Department
     P.O. Box 2627
     Detroit, MI 48231-2627


If your representative will assist you in prescription drug matters with Blue Cross Blue Shield of Michigan, mail the form to:

     Blue Cross Blue Shield of Michigan
     Pharmacy Help Desk – C303
     P.O. Box 807
     Southfield, MI 48037


If your representative will assist you in medical or prescription drug matters with Blue Care Network, mail the form to:

     BCN Advantage Grievance and Appeals Unit – C248
     Blue Care Network
     P.O. Box 284
     Southfield, MI 48086-5043

Still have questions? Call the phone number on the back of your Blues ID card for more help.

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Page Last Updated Wed Jul 16 10:31:05 EDT 2014