Appointment of Medicare Representative

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We want to make sure you receive quality care even if you can’t make decisions about your care on your own. Use this form to appoint a personal representative to act on your behalf for:

Print and complete this form and attach it to your request form. Mail them to an address listed below.

Instructions

  • Fill in your name and Medicare number.
  • Write the name of your appointed representative.
  • Sign and date the form. Include your 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 you.
  • To waive fees or payment for representation or provider or supplier services, sign and date sections III and IV.
  • Mail the form with your request to the appropriate address below.

If you’re filing a complaint, mail this form along with details of your complaint to:

HMSA Customer Relations
P.O. Box 860
Honolulu, HI 96808-0860

If you’re requesting an appeal, mail or fax this form with the appeal request to:

HMSA Member Advocacy & Appeals
P.O. Box 1958
Honolulu, HI 96805-1958

Fax: 808-952-7546 or 808-948-8206 on Oahu

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

If requesting medical care coverage, mail this form and your request to:

HMSA Medical Management Department
P. O. Box 2001
Honolulu, HI 96805-2001

If you have questions about this process, call us so we can help you: