You can name another person to act for you as your representative to ask for a coverage decision, make an appeal, or file a grievance (compliant).
How to name someone to help you
If you want a friend, relative, or other person to be your representative, you can complete the Appointment of Representative (AOR) form or an equivalent written notice.
To make sure you’re giving us all the information, you can call the Customer Care team and ask for the Appointment of Representative form. The form is also available at www.CMS.gov/Medicare/CMS- Forms/CMS-Forms/downloads/cms1696.pdf.
Here's how:
- Print the form, following the instructions to complete applicable sections
Both you and the person you want to act on your behalf will need to sign the form.
- Provide a copy of the signed form to us:
Priority Health Medicare Appeals
1231 East Beltline NE, MS 1150
Grand Rapids, MI 49525
Share through a secure message by logging into your member portal.
You can also deliver it in person at the above location, or fax it to us at 616.975.8827
We will keep your appointment of representative form on your record. This form is valid for one year from the date of signature.