Appointment of Medicare Representative

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You deserve the best care possible even if you choose to have someone else make health care requests on your behalf. Use this form to appoint a representative for:

Print and complete this form and attach it to your request form.

Instructions

  • Fill in your name and Medicare number.
  • Section 1: Fill in the name of your appointed representative and your telephone number and address.
  • Sign and date Section 1.
  • Section 2: Fill in your representative’s name, telephone number, address, and relationship to you.
  • Have your representative sign and date Section 2.
  • Section 3: If your representative is the provider or supplier, they cannot charge a fee to represent you in filing a grievance, organization determination, or appeal. Your representative also must sign and date this section.
  • Section 4: This does not apply to Medicare Advantage. Please leave this section blank.
  • The form is good for one year. Please keep a copy for your records in case you need to use it again.
  • 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 you’re 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 you’re 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: