MDwise Medicare
Appoint a Representative

How to Appoint a Representative

You have the right to have someone act on your behalf when you need help with filing an appeal or grievance or when making a coverage request. This person is called your appointed representative. Your appointed representative can be a relative, friend, or any other person you want to file an appeal or grievance or submit a coverage request for you.

To name someone to be your appointed representative, you must fill out and sign an Appointment of Representative form or provide us with the equivalent information. To get the form call Member Services at 833-358-2140 (TTY: 711) and ask for the Appointment of Representative form or download and print the Appointment of Representative form from the Medicare website.

Once you have the form, you must fill it out and both you and your appointed representative must sign. Completed, signed forms are valid for one year or for the duration of the individual appeal, grievance or coverage request if longer than one year.

You can mail the completed form to:

MDwise Medicare
Attn: Appeals & Grievances
PO Box 44092
Indianapolis IN 46244-0092

Your doctor, other provider, or prescriber can file an appeal or make a coverage request on your behalf without an Appointment of Representative form.

If you have a court appointed representative or someone with durable power of attorney, they do not need to complete the Appointment of Representative form.

CMS Material ID: H7746_MDwiseWebsite
Updated: 10/1/2021 12:29:35 PM