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Authorized Representative

If you need someone to file a grievance, coverage determination, organization determination, or appeal on your behalf, you can name a relative, friend, advocate, doctor, 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.

If you are requesting an organizational determination through an appointed representative, you should download the CMS-1696 Appointment of Representative Form (PDF), complete it and mail it to:

Appeal & Grievances
Medicare Operations
7700 Forsyth Blvd.
St. Louis, MO 63105

If you have questions, please call Member Services at 1-877-941-0482. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. Or you may FAX to us at 1-844-273-2671.