This form can be used to appoint a personal representative to act on the Medicare beneficiary’s behalf when requesting an appeal from HMSA or when requesting coverage for a prescription drug.
Please print out and complete this form and attach it to your appeal request form or drug review request form. The appropriate addresses are indicated below.
To appoint a personal representative, a Medicare beneficiary will:
- Fill in their name and Medicare number.
- Write the name of the individual being appointed as representative.
- Sign and date the form and give their address and telephone number.
- Have the representative write their name, sign and date the form, and fill in their address, telephone number, and relationship to the beneficiary.
- To waive fees or payment for representation or services (the latter in the case of providers or suppliers), sign and date sections III and IV.
- Mail the form to the appropriate address below.
A. If requesting an appeal, mail this form with the appeal request to:
HMSA Member Advocacy & Appeals
P.O. Box 1958
Honolulu, HI 96805-1958
Or fax to: 808-952-7546 or 808-948-8206 on Oahu
B. If requesting coverage for a prescription drug, mail this form with the drug review request form to:
Medicare Coverage Determinations and Appeals
MC109 P.O. Box 52000
Phoenix, AZ 85072-2000