Can someone file an appeal for you?

Contact your State Health Insurance Assistance Program (SHIP) if you need help filing an appeal.

You can also appoint a representative—like a family member, friend, advocate, attorney, doctor or someone else—to act on your behalf.

In some cases, your doctor can make a request for you 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

  1. Fill out the "Authorization to Disclose Personal Health Information" form.
  2. Submit a letter with the following:
    • Your name, address, and phone number
    • Your Medicare number
    • A statement appointing someone as your representative
    • Your representative's name, address and phone number
    • Your representative's profession or his/her relationship to you
    • A statement allowing your representative to get your personal and identifiable health information
    • A statement explaining why you're being represented
    • Your signature and the date you signed the letter
    • Your representative's signature and the date they signed the letter

You must send the form or letter to the company that handles bills for Medicare or, if appealed, with your appeal request. 

Note
  • 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.