1-877-998-LIFE (5433)

1-877-998-LIFE (5433)

CMS Appointment of Representative

How to Appoint a Representative

An authorized representative is the person you choose to handle affairs related to your health care services. This may be someone you designate as a Power of Attorney, a family member, friend, caregiver, or an advocate of your choice. To become an authorized representative, you’ll need to download and print CMS Appointment of Representative Form (CMS Form1696). Both you and the person you wish to represent will need to sign the form.

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Fill out the form and one of our dedicated team members will contact you.

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