Appointment Representation

HOW TO APPOINT A REPRESENTATIVE FOR AN APPEAL

You can appoint a representative to help you with an appeal. Your representative can be a family member, friend, advocate, attorney, doctor or someone else who will act on your behalf. There are two ways to appoint a representative for an appeal.

  • Your name, address, and phone number
  • Your Medicare number
  • A statement appointing someone as your representative
  • The name, address, and phone number of your representative
  • The professional status of your representative or their relationship to you
  • A statement authorizing the release of your personal and identifiable health information to your representative
  • A statement explaining why you’re being represented
  • Your signature and the date you signed the request
  • Your representative’s signature and the date they signed the request
  • Be sure to keep a copy of your letter or form 1696.

If you want someone to talk to Brand New Day for you

Brand New Day is not allowed to speak with others about your membership, your health status, your care, or any other private matter unless you ask us to do so. If you want someone else to speak for you, please complete the form described below and mail or fax it to Brand New Day.

Mail to:

Brand New Day, Enrollment Dept.
5455 Garden Grove Blvd., Suite 500
Westminster, CA 92683

Fax to: 657-400-1207, Attn: Enrollment Department

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