If you want to appoint someone to help you with a Medicare coverage decision, appeal or grievance, you need to fill out an Appointment of Representative form (PDF). This form lets you pick a person like a spouse, friend, family member, lawyer or caregiver to make decisions for you. You can't pick a law firm or group to help you.
Each person you choose to make decisions for you must fill out a part of the form called Acceptance of Appointment. They need to add their contact details and sign the form.
If the person helping you isn't charging you a fee, they need to fill out the Waiver of Fees section.
If you have a power of attorney agreement, you can use that instead of this form.
Once you complete the form, you’ll need to mail it to the appropriate department.
If your representative will help 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 help you in prescription drug matters with Blue Cross Blue Shield of Michigan, mail the form to:
Blue Cross Blue Shield of Michigan
Clinical Pharmacy Help Desk - 1610
P.O. Box 32877
Detroit, MI 48232-1127
If your representative will help you in medical matters with Blue Care Network, mail the form to:
BCN Advantage Grievance and Appeals Unit
Blue Care Network
P.O. Box 284
Southfield, MI 48086-5043
Fax: 1-866-522-7345
Email: BCNGrievance@bcbsm.com
If your representative will help you in prescription drug matters with Blue Care Network, mail the form to:
Blue Care Network
Pharmacy Clinical Help Desk
Mail Code TC1308
P.O. Box 807
Southfield, MI 48037
Fax: 1-866-601-4428