Appointing a Representative
You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under State law to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative. To learn how to name your appointed representative, you may call Customer Service toll-free at 1-877-883-9577 (TTY 711) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Mar. 31, representatives also are available weekends from 8 a.m. to 8 p.m.
You also have the right to have a lawyer act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.
The representative statement must include your name and Medicare number. You may use Medicare's Form for Appointment of a Representative (CMS1696)Open a PDF.You may also use an equivalent notice which satisfies the requirements in Form CMS-1696. Unless otherwise stated, your appointed representative will have all the rights and responsibilities of you.
Univera Healthcare is an HMO plan with a Medicare contract. Enrollment in Univera Healthcare depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_8096_C.
This page last updated 10-01-2021.