Appointing a Representative

What is representative?

A representative is a person who is appointed or authorized by you to act on your behalf in requesting health care and/or prescription drug services or filing a grievance or an appeal. You may appoint any person, such as a relative, friend, advocate, attorney, or any physician, as your representative.

How do I appoint a representative?

You can appoint a representative when you and your representative complete, sign, and date an Appointment of Representative form CMS-1696 and send it to us when requesting health care and/or prescription drug services or filing a grievance or an appeal. You may download a copy of the CMS-1696 Appointment of Representative form below:
For English:
Appointment of Representative

For Spanish:
Nombramiento de un Representante

  • Your representative may also be a court appointed guardian, an individual who has a Durable Power of Attorney, or a health care proxy, or a person designated under a health care consent law.
  • You may also appoint a representative by providing written notice that includes the following:
  • Your name, address, and telephone number;
  • Your Health Insurance Claim Number (HICN) or Medicare Identifier (ID) number;
  • The name, address, and telephone number of the person you appoint as your representative;
  • A statement from you authorizing your representative to act on your behalf;
  • Your signature and date;
  • Your representative's signature and date; and
  • A statement from your representative that he/she has accepted the appointment.

Can my primary care or other doctor act on my behalf?

Yes. Your primary care doctor or another doctor that you have seen more than one time can also act on your behalf to request health care and/or prescription drug services, or file an appeal for services that have been denied. These doctors do not need to be appointed in writing, however, they must tell you about any action they take on your behalf.

How long is my appointment good for?

Unless you revoke your appointment, it is good for one year from the date that the appointment was signed by both you and your representative. Your representative will need to provide BCBSAZ Advantage a copy of your signed and dated appointment whenever your representative acts on your behalf in requesting health care and/or prescription drug services, or when filing a grievance or an appeal.