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Authorized Representative

Authorized Representative – Instructions & Form

An appointed representative is a person who can act on your behalf to request an appeal or complaint. If you need someone to file a grievance, coverage determination, organization determination, or an appeal on your behalf, you can name a relative, friend, advocate, or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

You can use the Appointment of Representative (AOR) form CMS-1696*  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. Physicians and other prescribers may request a redetermination on your behalf at any time without completing an AOR form.

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

  • Includes the name, address, and telephone number of enrollee;
  • Includes the enrollee's HICN [or 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

The signed AOR form or ‘equivalent written notice’ must be included with each oral or written request for an appeal or grievance. Unless revoked, an appointment is valid for one year from the date that the AOR form is signed by both the member and representative.

Send your AOR form or equivalent written notice to For Part C (Part B Drugs) Medical Services Appeals, and Part C and D Grievances.

Health Net Community Solutions, Inc.
Appeals and Grievances Dept.
P.O. Box 10422
Van Nuys, CA 91410-0422
Fax: 1-877-713-6189

For Part D Prescription Drug Appeals:

Health Net Community Solutions, Inc.
Attn: Medicare Pharmacy Appeals
P.O. Box 31383
Tampa, FL 33631-3383
Fax: 1-866-388-1766

If you have questions, please call Member Services. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends, and on holidays, you can leave a message. Your call will be returned within the next business day.

*By clicking on these links you will be navigating away from Health Net Cal MediConnect's website.