Appointment of Representative
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Abrazo Advantage Health Plan members who want to appoint an individual to act on their behalf when filing an appeal, requesting a coverage determination or exception, may do so by completing an Appointment of Representative form.
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A copy of the Appointment of Representative form is provided below:
| Appointment of Representative Form |
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Who can be appointed as a representative by a member?
A member can authorize anyone (such as a relative, friend, advocate, an attorney, or a doctor) to act as his or her representative on his or her behalf.
A representative (or surrogate) may be authorized by the court or act on behalf of the member in accordance with State law to file an appeal for an enrolled member. A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney, or a health care proxy, or a person designated under a health care consent statute.
How to appoint a representative:
- The member and the representative accepting the appointment (including attorneys) must sign, date, and complete an Appointment of Representative form. (see link above for form)
- If a member is incapacitated or legally incompetent a surrogate is not required to submit an Appointment of Representation form. The surrogate will need to submit copies of the legal papers supporting his or her status as the member's authorized representative to the Grievance and Appeals department at the address below.
- A copy of the completed and signed Appointment of Representative form is required in order for Abrazo Advantage Health Plan to process an appeal filed by the member's representative and will be valid during the entire appeal process. Unless revoked by the member, the Appointment of Representative form is valid for one year from the date that the appointment is signed by both the member and the representative.
Submit a completed Appointment of Representative form to:
Abrazo Advantage Health Plan
Grievance & Appeals Department
7878 N. 16th Street, Suite 105
Phoenix, AZ 85020
To honor the best interest of the individual, the person who is appointed as a health care representative should be made aware of the philosophies and ideologies of the individual they represent.
H5985_502-2011 Pending CMS Approval