A Blue Shield of California Medicare plan enrollee may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as his or her representative and file an appeal on his or her behalf.

Also, the court may authorize a representative (surrogate) to 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 healthcare consent statute
  • an executor of an estate.

To make this designation, both the enrollee making the appointment and the representative accepting the appointment must sign, date, and complete a representative form.

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

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

  • Medicare plan member's/enrollee's name, address, telephone number, Health Insurance Claim Number (HICN), or Medicare Identifier (ID) or plan ID number
  • Name of the individual being appointed and the appointee's address, telephone number and professional status or relationship to the member

The form should also contain 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. The notice must be signed and dated by both the enrollee making the appointment and the individual being appointed as representative, and must include a statement that the representative accepts the appointment. The supporting authorized representative's status must be included with each appeal.

An Appointment of Representative is 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.

A photocopy of the signed representative form must be submitted with future appeals on behalf of the enrollee in order to continue representation. However, the photocopied form is only good 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; a new form must be executed by the enrollee.

Appointment of representative form

Download and print a form in your preferred language:

Appointment of Representative form, English (PDF, 62 KB)
Appointment of Representative form, Español (PDF, 37 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.

Blue Shield also provides the option to use its authorization form to authorize a third party access to
your Protected Health Information (PHI). You can find this form in other languages as well.