As a person with Medicare, you may appoint a representative, such as a family member, friend, or health care provider, to act on your behalf to:

• Request a coverage determination or an appeal.
• File a quality of care concern.

You and your representative must first complete the “Appoint a Representative” form (CMS Form Number 1696).

If you have questions about appointing a representative, call 1-800-MEDICARE (1-800-633-4227). TTY/TTD users should call 1-877-486-2048.