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 [PDF, 47.7 KB].
- 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
You may not need to appoint your doctor or prescriber (for prescription drug appeals) as your representative. At some levels in the appeals process, they can submit a request for you without being appointed as your representative.
If you have questions about appointing a representative,
- 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.