Appointment of Representative Form Tutorial

For more information on how to complete the Appointment of Representative form, move your cursor over any field in the interactive form below; you'll see instructions on how to complete the field. You may also click in any field for more detailed instructions.

Appointment of Representative Form
Name of represented party (beneficiary, provider or supplier) Medicare number (HIC) or National Provider Identification Number (NPI) Name of representative appealing on behalf of party Hand written signature of party required (beneficiary, provider or supplier) Provider's state Provider's phone number (xxx-xxx-xxxx) Provider's street address Provider's City Must be within 30 days of appointed representative's signature. Valid for 1 year from oldest date signed. Provider's ZIP Code Name of representative appealing on behalf of party The relationship of the individual to the party Hand written signature of appointed representative required Appointed Representative's State. Correspondence will be sent to this address. Appointed representative's phone number (xxx-xxx-xxxx) Appointed representative's street address. Correspondence will be sent to this address. Appointed Representative's City. Correspondence will be sent to this address Must be within 30 days of party's signature. Valid for 1 year from oldest date signed. Appointed representative's Zip Code. Correspondence will be sent to this address. Name of represented party (Beneficiary, provider or supplier) Hand written signature of appointed representative Date signed Date signed Hand written signature of appointed representative. This is only required if the provider or supplier is also acting as the representative for the beneficiary.

 

Last Updated Mar 28 , 2022