Contact your State Health Insurance Assistance Program (SHIP) if you need help filing an appeal.
You can also appoint a representative if you need help filing an appeal. Your representative can be a family member, friend, advocate, attorney, doctor or someone else to act on your behalf.
In some cases, your doctor can make a request on your behalf without being appointed your representative:
- Your doctor or other prescriber can request a coverage determination or redetermination for you and you don't need to submit an "Appointment of Representative" form.
- If you want your doctor or other prescriber to request an appeal from the Independent Review Entity (IRE) or at a higher level of appeal, you'll need to send in this form.
2 ways to appoint a representative
- Fill out an "Appointment of Representative" form.
- Submit a written request that includes:
- 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
- A statement authorizing the release of your personal and identifiable health information to your representativeThe professional status of your representative or their relationship to you
- 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
You must send the form or written request to the company that handles bills for Medicare or, if appealed, with your appeal request.
If you have questions about appointing a representative, call 1-800-MEDICARE.
- Write your Medicare number on all documents you submit with your appeal request.
- Keep a copy of everything you send to Medicare as part of your appeal.