A Blue Shield Cal MediConnect Plan enrollee may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as his or her representative when filing a grievance, requesting a determination, or in dealing with any level of the appeals process on his or her behalf.

Also, a representative (surrogate) may be authorized by the court or act in accordance with State Law to file an appeal for an enrollee. A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney, a health care proxy, a person designated under a health care consent statute or an executor of an estate.

To be appointed by an enrollee, both the enrollee making the appointment and the representative accepting the appointment must sign, date and complete The Appointment of Representative form. The Appointment of Representative form does not give Blue Shield Promise Cal MediConnect Plan written permission to use/disclose Protected Health Information (PHI) to another company or person (such as a friend or family member). An appointment of representative by an enrollee is considered valid for one year (unless revoked) from the date that the appointment is signed by both the member and the representative. Also, the representation is valid for the duration of the appeal.

Due in part to an incapacitated status or legally incompetent status of an enrollee, a surrogate is not required to produce a representative form. Instead, he or she must produce other appropriate legal papers supporting his or her status as the enrollee's authorized representative.

Appointment of representative form

Download and print a form in your preferred language:
English (PDF, 71 KB)
Spanish (PDF, 25 KB)

You may also obtain a copy of the Centers for Medicare & Medicaid Service's Appointment of Representative Form and other related forms from the Medicare.gov website.

A signed Appointment of Representative Form or an equivalent written notice should include the following:

  • Member's name, address, telephone number, Medicare Identifier (ID) or HICN or plan ID number
  • The name of the individual being appointed name, address, telephone number and professional status or relationship to the member.
  • A statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s) at issue
  • A statement authorizing disclosure of individually identifying information to the representative

The notice should be signed and dated by the enrollee making the appointment and by the individual being appointed as representative and accompanied by a statement that the individual accepts the appointment.

You may mail or fax your completed form to:
  Blue Shield of California Promise Health Plan
601 Potrero Grande Dr.
Monterey Park, CA 91755
  Fax: (323) 889-6577

The documents supporting authorized representative's status must be included with each appeal. A photocopy of the signed representative form must be submitted with appeals on behalf of the enrollee. The photocopied form is only valid for one year after the date of the enrollee's signature. Any appeal received with a photocopied representative form that is more than one year old is invalid to appoint that person as a representative; a new form must be signed by the enrollee.