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An appointed representative is a person who can act on your behalf to request an appeal or complaint. If you need someone to file a grievance, coverage determination, organization determination, or an appeal on your behalf, you can name a relative, friend, advocate, or anyone else as your appointed representative.

Title: Appointment Affidavit. Form #: SF61. Current Revision Date: 08/2002. Authority or Regulation: The Guide to Processing Personnel Actions.

Appointment of Authorized Representative Use this form to appoint an individual or organization as your Medi-Cal authorized representative. Your authorized representative may act for you on all duties related to your Medi-Cal eligibility and enrollment. Or, you may also limit duties.

Appointment of Authorized Representative (Purpose: To grant permission for another individual or company to act on your behalf in filing a Grievance or Appeal).

Appointment of representative form for appeals and grievances. If you are filing an appeal or grievance on behalf of a member, you need an Appointment of Representative (AOR) form or other appropriate legal documentation on file with Humana so that you are authorized to work with Humana on his or her behalf.

To be appointed as the applicant's representative, the case manager must complete the SSA-1696: Appointment of Representative form.

You can use the Appointment of Representative (AOR) form CMS-1696* or you can make your own statement (an equivalent written notice) as long as it contains all the required information. In addition, we may also accept other forms of legal documentation.

Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.