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. If you want someone to act for you, then you and that person must complete the Appointment of Representative form (requires Adobe Reader), OMB no. 0938-0950.

Mail completed forms to:

Attn: CLIENT SERVICES DEPARTMENT
Health Alliance Plan/Alliance Health & Life Insurance Co.
2850 West Grand Boulevard
Detroit, Michigan 48202

Instructions for completing the Appointment of Representative Form
Please note: You do not 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

Sections 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/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/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.