Appointing a representative

You have the right to appoint someone to act on your behalf. You can name a relative, friend, advocate, doctor or anyone else to be your appointed representative. This appointed representative may request a coverage determination on your behalf, as well as file a grievance or appeal.

Appointment of Representative form

If you want someone to act for you, you and that person must complete an Appointment of Representative form. Download the Appointment of Representative form (PDF).

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Instructions for completing the Appointment of Representative form

Please note: You don’t have to appoint your prescribing physician to act on your behalf in requesting an initial coverage determination. Enter your name (as beneficiary) and Medicare number in the top two spaces of the form.

Section I

– To be completed by the beneficiary (plan member):

• Enter the name of the individual being appointed
• Sign your name and date the form in Section I
• Provide your complete address and phone number

Section II

– To be completed by the appointed representative

• Enter representative’s name and relationship to the beneficiary
• Representative must sign and date the form in Section II
• Provide the representative’s complete address and phone number

Section III

– This section should be filled out if the representative waives a fee for such representation. If the representative is a provider or supplier of medical services, he or she must complete this section:

• Enter the beneficiary’s name
• Representatives waiving a fee must sign and date the form in Section III

Section IV

– If the person you appoint as a representative is a provider who has already provided services to you, he or she must complete this section waiving the right to charge you for the services. Providers or suppliers must sign and date the form in Section IV.

Mail completed forms to:

Attn: Customer Service Department
Health Alliance Plan/Alliance Health & Life Insurance Co.
1414 E Maple Rd.
Troy, MI 48083

Know your medical rights

Unexpected illnesses or accidents can create confusion around important medical decisions. Under the Durable Power of Attorney and Designation of Patient Advocate Act, you have the right to appoint a representative to make decisions about your care, custody and medical treatment. By doing so now, you can make sure you're prepared in case you’re ever unable to make these decisions on your own.

Learn more about your medical rights (PDF).

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Have questions?

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