Appointing a Representative

You have the right to appoint someone to act on your behalf. You can name a relative, friend, advocate, doctor or anyone else to be your appointed representative. This appointed representative may request a coverage determination on your behalf, as well as file a grievance or appeal.

Appointment of Representative form.

If you want someone to act for you, then you and that person must complete an Appointment of Representative form.


Instructions for completing the Appointment of Representative form.

Please note: You do not have to appoint your prescribing physician to act on your behalf in requesting an initial coverage determination. Enter your name (as beneficiary) and Medicare number in the top two spaces of the form.

Section I – To be completed by the beneficiary (plan member)

  • Enter the name of the individual being appointed
  • Sign your name and date the form in Section I
  • Provide your complete address and phone number
Section II – To be completed by the appointed representative
  • Enter representative’s name and relationship to the beneficiary
  • Representative must sign and date the form in Section II
  • Provide the representative’s complete address and phone number
Section III – This section should be filled out if the representative waives a fee for such representation. If the representative is a provider or supplier of medical services, he/she must complete this section.
  • Enter the beneficiary’s name
  • Representatives waiving a fee must sign and date the form in Section III
Section IV – If the person you appoint as a representative is a provider who has already provided services to you, he/she must complete this section waiving the right to charge you for the services. Providers or suppliers must sign and date the form in Section IV.

Health Alliance Plan/Alliance Health & Life Insurance Co.
2850 W. Grand Blvd.
Detroit, MI 48202

Know Your Medical Rights.

Unexpected illnesses or accidents can create confusion around important medical decisions. Under the Durable Power of Attorney and Designation of Patient Advocate Act, you have the right to appoint a representative to make decisions about your care, custody and medical treatment. By doing so now, you can make sure you're prepared in case you are ever unable to make these decisions on your own.

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Have questions?

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