Part C Formularies
Medical Care and Services

Learn more about our Grievances and Appeals request

Apointment of representative

Learn about our request for Appointment of Representative:

Press here to fill the CMS Appointment of Representative Form.

General Instructions to complete MCS Classicare Appointment of Representative Form.

You may appoint any person to act on your behalf to file a grievance or an appeal. You must sign, date, and complete a representative form called "Appointment of Representative". This authorization will be included with each grievance or appeal and will be valid for one (1) year from the date that the form is signed by both: you and your representative. In all future cases, a photocopy of the signed representative form must be submitted to continue representation.

Please be sure to include all the information requested in the Appointment of Representative Form:

• Name of Party: This is your name (name of Beneficiary) or entity which has a standing to file a claim or appeal (the name of the person who has Medicare, or the name of the provider or supplier). This is a required field.
• Medicare number (beneficiary as party) or National Provider Identifier (NPI) (provider or supplier as party): This is your (beneficiary) Medicare number as it appears in your Traditional Medicare Card. This is a required field.
• Section 1: This section should be completed by you (the beneficiary). This is a required field. Include the name of the person that you want to appoint as your representative in the first line of the section I. Also, sign it, include the current date, your address, and your phone number.
• Section 2: This section should be completed by the person that you want to appoint as your representative. Your representative should include his/ her signature, the current date, his/her address and his/her phone number. This is a required field.
• Section 3: This section should be completed only if your representative waives a fee for such representation. In case of providers that furnished the services at issue, they must complete this section. A provider or supplier may not charge a fee for representation. Otherwise, leave it in blank.
• Section 4: This section should be completed only by providers or suppliers serving as a representative to whom they furnished the item or services at issue, if the appeal involves a question of liability under section 1879(a)(2) of the Act. Otherwise, leave it in blank.