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.
- 1. Fill out an appointment of representative form (CMS form 1696):
If you don’t want to use the form you may;
- 2. Write a letter to us telling us that you want to appoint a representative. Include the following information:
- 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.
5455 Garden Grove Blvd., Suite 500
Westminster, CA 92683
Fax to: 657-400-1207, Attn: Enrollment Department