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Authorized Representative

An appointed representative is a person who can act on your behalf to request an exception appeal or complaint. 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. Please note that your physician or other prescriber is not required to submit a signed Appointment of Representative (AOR) form CMS-1696 or other equivalent notice. Physicians and other prescribers may request a redetermination on your behalf at any time without completing an AOR form.

You can use the AOR form or you can make your own statement.

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.

You can use the form or you can make your own statement (an equivalent written notice) as long as it contains all the required information. In addition, Cal MediConnect 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 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

Send your AOR form or equivalent written notice to:

Appeals and Grievances Dept.
P.O. Box 10422
Van Nuys, CA 91410-0422