Skip to Main Content

Authorized Representative

As a Medicare beneficiary, you have the right to appoint a representative to act on your behalf. An appointed representative can be a relative, friend, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

To appoint a representative, you and your appointed representative need to complete the Appointment of Representative Form and sign where indicated. Please click the Appointment of Representative Form (CMS-1696) link below to access this form. Once you have printed, completed and signed the form, please mail it to the following address:

1 Campus Martius, Suite 700
Detroit, MI 48226

Review information on Advance Directives