![]() Others may already be authorized under state law to be your representative. You can also use the Social Security Administration Appointment of Representative form (Form SSA-1696-U4) found online or at Social Security offices. You can use the CMS Appointment of Representative form (CMS-1696-U4) located on the Medicare Advantage Plan Documents page by selecting your plan. The representative statement must include your name and Medicare claim number. If you choose a lawyer, only you need to sign the representative statement. The representative needs to have the appropriate legal papers or legal authority to sign for you. If you are legally not of sound mind or are incapacitated, the representative can complete and sign the statement. ![]() You and the person you choose must sign, date, and complete a representative statement.Ī request may also be made in a written letter. You may choose someone to act on your behalf. This person may be a relative, friend, sponsor, lawyer, or a doctor. You can also send us your grievance in writing by mail or by fax. If you have a grievance, we ask you to first call Customer Service at 1-87 (TTY 711).
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