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Appointment of Representative

You can appoint someone (such as a relative, friend, advocate, attorney, or physician) to act as your representative to file a grievance, request an organization or coverage determination, or deal with any of the levels of the appeals process by filling out CMS Form-1696 below. The form must be signed by you and by the person you would like to appoint as your representative. This form does not allow your representative to make healthcare decisions for you.

If you want to appoint someone to act as your representative and make healthcare decisions for you, you may either complete the Personal Representative Request form below, or provide us with your existing health care Power of Attorney document.

You can appoint someone to receive your Protected Health Information (PHI) by filling out the HIPAA Authorization Form below.

Please mail completed forms to Member Services at:

Central Health Medicare Plan
ATTN: Member Services
1540 Bridgegate Drive
Diamond Bar, CA 91765

Appointment of Representative Form CMS 1696 (PDF - 48 KB)
Personal Representative Request (PDF - 232 KB)
HIPAA Authorization Form (PDF - 116 KB)



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