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
PO Box 14244, Orange, CA 92863
Appointment of Representative Form
( English
| Spanish
| Chinese
| Korean
| Vietnamese
)
Personal Representative Request
( English
| Spanish
| Chinese |
Vietnamese)
HIPAA Authorization Form
( English |
Spanish |
Chinese |
Vietnamese
)
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