Appointment of Representative Form

You may appoint a relative, friend, advocate, attorney, or your physician to act as your representative. A representative who is appointed by the court or active in accordance with state law may also file an appeal or grievance on your behalf.

 

How do I appoint a representative?

To appoint a representative, you must complete an Appointment of Representative Form ( English | Español ). You can print and complete this form by hand or use digital type. At the top, enter your full name and Medicare number. If you appoint more than one person, please complete a form for each of them.

Please fax or mail the form to:

Clover Health
P.O. Box 471
Jersey City, NJ 07303
Fax: 1-551-226-5351

For incapacitated or legally incompetent enrollees for whom there are appropriate legal papers or other legal authority, such supporting documentation may be submitted as evidence of representation.

 

Section I: Appointment of Representative

Give the name and address of the person you're appointing. You may appoint a relative, friend, advocate, attorney, your physician, or any other qualified person to represent you. Additionally, you must date and sign this section as the beneficiary, providing your address and phone number as well. 

 

Section II: Acceptance of Appointment

Each person you appoint (named in Section I) completes this section. If the individual isn't an attorney, they must provide their name and state their acceptance of the appointment, signing the form as well.

 

Section III: Waiver of Fee for Representation

Your representative may complete and sign this section if they won't be charging any fees for their representation. Remember that a new form must be submitted with each grievance and appeal you submit.