Appointment of Representative (AOR)

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.

• Appointment of Representative Form (CMS-1696) 
• Nombramiento de Representante

If you would like to appoint a representative, you and your appointed representative must complete this form and mail it to Molina Medicare at:

Molina Medicare
7050 Union Park Center, Suite 600
Midvale, UT 84047

Protected Health Information (PHI)

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

• Protected Health Information Form 

Please complete this form and mail it to Molina Medicare at:

Molina Healthcare
Attn: Service Fulfillment
200 Oceangate, Ste 100
Long Beach, CA 90802

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