Appointment of Representative

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 to act in accordance with State Law to file an appeal for an enrollee. A representative 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 representative is not required to produce a representative form in the case of an incapacitated or legally incompetent status of an enrollee. Instead, they 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 or enrollee’s name
  • Medicare plan member’s or enrollee’s address
  • Medicare plan member’s or enrollee’s phone number
  • Medicare plan member’s or enrollee’s Health Insurance Claim Number (HICN)
  • Medicare plan member’s or enrollee’s Medicare Identifier (ID) or plan ID number
  • Appointee’s name
  • Appointee’s address
  • Appointee’s phone number
  • Appointee’s 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. It must also include 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 appointee as representative. Please 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. 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. The enrollee must execute a new form.  

 

Appointment of representative form

Download and print a form in your preferred language:

Appointment of Representative form

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 third-party access to your protected health information (PHI) . You can find this form in other languages as well. 

  • English (PDF, 97 KB)
  • Español (PDF, 104 KB)
  • Arabic (PDF, X KB)
  • Armenian (PDF, X KB)
  • Cambodian (PDF, X KB)
  • Chinese (Simplified) (PDF, X KB)
  • Chinese (Traditional) (PDF, 164 KB)
  • Farsi (PDF, X KB)
  • Korean (PDF, X KB)
  • Russian (PDF, X KB)
  • Tagalog (PDF, X KB)
  • Vietnamese (PDF, 225 KB)

Y0118_23_408A3_M Accepted 12102023

H2819_23_408A3_M Accepted 12102023

Page last updated: 1/1/2024

*Free copy with no obligation to enroll.

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California Physician’s Service DBA Blue Shield of California is an independent member of the Blue Shield Association.

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For Blue Shield Medicare Advantage Plans: Blue Shield of California is an HMO, HMO D-SNP, PPO and a PDP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Blue Shield of California depends on contract renewal.

 
 
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