How to Appoint a Representative?

You can name another person to act as your representative to file a grievance, appeal, or coverage determination on your behalf.

To appoint someone as your representative, you may use the Appointment of Representative Form below. You and your representative will both need to complete, sign, and date the form before sending it to CarePlus.

You will not need to complete an Appointment of Representative Form if you provide an equivalent written notice or other legal representation document with your request. A representative who is appointed by the court or who is acting in accordance with state law can file a request for you after sending us the proper legal documentation.

Appointment of Representative Form 

If you would like to appoint a representative, download and complete this form before providing it to CarePlus.

Appointment of Representative Form: English | Spanish 

You may also retrieve these forms from the Centers for Medicare & Medicaid (CMS) website. 

Instructions When Appointing a Representative 

The instructions below outline how you can appoint a representative: 

How to Appoint a Representative : English | Spanish   

Sharing your Health Plan Information

If you or your representative need CarePlus to discuss private health information (PHI) with another person or organization, please complete a Consent for Release of PHI Form.

Consent for Release of PHI Form

• English Consent for Release of PHI Form  
  
• Spanish Consent for Release of PHI Form