Appoint a Representative

According to Medicare guidelines, an appointed representative is a person who can act on your behalf to request an exception, appeal or grievance. This person can be a relative, friend, advocate, doctor, or anyone else whom you trust to act on your behalf. If you want to appoint someone to act for you, then both you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. Physicians and other prescribers who are providing your treatment may, upon providing notice to you, request for a pre-service redetermination on your behalf without completing an Appointment of Representative (AOR) form.

The signed AOR form or other equivalent notice must be included with each oral or written request for an appeal or grievance. Unless revoked, an appointment is considered valid for one year from the date that the representative form is signed by both the Member and representative. Also the representation is valid for the duration of the appeal or grievance. A photocopy of the signed representative form must be submitted with future appeals or grievances on behalf of the Member in order to continue representation. However the original or photocopied form is only valid for one year after the date of the Member's signature.

Send your statement to the following address:

Appeals & Grievances Medicare Operations
PO Box 10450
Van Nuys, CA 91410-0450

You can use the form that is attached at the bottom of this page or you can make your own statement (an equivalent written notice) as long as it contains all the required information.

(In addition, we may also accept other forms of legal documentation)

The required information of an 'equivalent written notice' is one that:

• Includes the name, address, and telephone number of enrollee;
• Includes the enrollee's Medicare Identifier (ID) Number;
  
• Includes the name, address, and telephone number of the individual being appointed;
• Contains a statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to the representative;
• Is signed and dated by the enrollee making the appointment; and
• Is signed and dated by the individual being appointed as representative, and is accompanied by a statement that the individual accepts the appointment

If you need assistance in naming your appointed representative, you can call us at one of the numbers listed below.

Health Net Customer Service

April 1 – September 30 *
Monday through Friday, 8:00 a.m. to 8:00 p.m.

October 1 – March 31 *
7 days a week, 8:00 a.m. to 8:00 p.m.

* A messaging system is used after hours, weekends, and on federal holidays.

Calls received after hours will be handled by our automated phone system and a Health Net representative will call you back on the next business day.

Link to the Centers for Medicare and Medicaid Services

(CMS) Appointment of Representative Form CMS-1696