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.Download
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
- 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
- Enter the beneficiary’s name
- Representatives waiving a fee must sign and date the form in Section III
MAIL COMPLETED FORMS TO:
Attn: CUSTOMER SERVICE DEPARTMENT
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.Learn More
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