Appointment of Representative
PHC California members may appoint any person such as a relative, friend, advocate, attorney, physician, or an employee of a pharmacy to act as his or her representative to file a grievance, request a coverage decision or exception, or request an appeal on their behalf.
If you would like to appoint a representative to act on your behalf, please download the Appointment of Representative Form (Form CMS-1696). (By clicking on this link, you will be downloading a file from the Centers for Medicare and Medicaid Services website.)
We also accept written equivalents of this form that must include:
- Your name, address and telephone number
- The name, address and telephone number of the person you are appointing to represent you
- A statement that says you are authorizing your representative to act on your behalf for the medical service(s) or claim(s) at issue
- A statement that you authorize disclosure of your personal health information to your representative
- Your signature and date
- A statement from the person you are appointing to represent you that says he or she accepts the appointment
- The signature and date of the person you are appointing to represent you
Members may also appoint a representative to act on their behalf under a durable power of attorney for health care or by another legal documentation. If you have any questions about appointing a representative to act for you, please contact Member Services.
DHCS 030716 PHC Form 1.0