Appointment of Representative

Appointment of Representative

Individuals who represent enrollees may either be appointed or authorized.

The Appointment of Representative form is a CMS form that allows a third party to act as your representative when filing a grievance, requesting a determination or in dealing with any levels of the appeals process. The Appointment of Representative form does not give Blue Shield Promise Cal MediConnect Plan written permission to use/disclose PHI to another company or person (such as a friend or family member). You may mail or fax your completed form to:

Blue Shield of California Promise Health Plan
Member Services
601 Potrero Grande Drive
Monterey Park, CA 91755

Fax Blue Shield of California Promise Health Plan at (323) 889-6577

CMS Link to Appointment of Representation form can be found HERE
 
Or you may also print the CMS'Appointment of Representative form in your preferred language below:

English Spanish



Material ID: H0148_19_028_WEB
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