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 family member, friend, relative, advocate, or anyone else whom you trust to act on your behalf.

To appoint a representative, download the CMS form 1696, complete the form and print. Both you and the person you wish to represent you will need to sign the form. Download the Appointment of Representation CMS Form 1696 here (PDF).

CMS and PA SAA approved 11/29/2021