You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.
There may be someone who is already legally authorized to act as your representative under State law.
If you want a friend, relative, your doctor or other provider, or other person to be your representative, fill out the form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must mail the signed form to the Member Services Department