Who May Ask for a Coverage Determination?

You or someone you name to act for you (your appointed representative) may request a coverage determination (including exception). You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. Please fill out the Appointment of Representative form and send it to us with your request. You can call us at: 1-888-394-4327 (TTY/TDD 1-888-542-3821) if you need help filling out the form or want to learn more about appointing a representative.

> Appointment of Representative form (English / Español)

The Appointment of Representative form is also available by visiting the CMS website.
* Please note that clicking on this link will take you away from the Healthfirst website.