Contact your State Health Insurance Assistance Program (SHIP) if you need help filing an appeal.
Or, you can appoint a representative to help you. Your representative can be a family member, friend, advocate, attorney, doctor or someone else who will act on your behalf.
2 ways to appoint a representative
- Fill out an "Appointment of Representative" form.
- Submit a written request with your appeal. Be sure to include:
- Your name, address, phone number, and Medicare number
- A statement appointing someone as your representative
- The name, address, and phone number of your representative
- The professional status of your representative (like a doctor) or their relationship to you
- A statement authorizing the release of your personal and identifiable health information to your representative
- A statement explaining why you’re being represented and to what extent
- Your signature and the date you signed the request
- Your representative's signature and the date they signed the request
At some levels in the appeals process, your doctor or prescriber (for prescription drug appeals) can make a request on your behalf without being appointed as your representative.
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.