Name someone to act for you
A plain written statement naming a family member, friend or advocate to speak and write to your health plan for you about a claim or appeal. It does not replace the plan's own form.
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- A template, not legal advice
When to use this, and what it is not
When to use this. Use this when someone else will call or write to your plan for you. This letter does not replace your plan's own authorized representative form. Ask the plan for its form as well, complete it, and send both together. For a Medicare appeal, the form is called Appointment of Representative (number CMS-1696) and is published by the Centers for Medicare & Medicaid Services. If you cannot sign for yourself, ask the plan what it accepts. For job-based plans, the federal claims rule says that in an urgent case a health care professional who knows your condition must be allowed to act as your representative. Other coverage types have their own rules.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the plan or program you are authorizing someone to deal with]
Re: Name someone to act for you Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
Authorization to act for me with my health plan
I, [Your name], name [The full name of the person who will act for you], [Their relationship to you], as my authorized representative with [Name of the health plan], member ID [Member ID].
This covers: [What this covers]. The matter I mean is claim [Claim or reference number], for [The care or drug that was denied], from [Doctor, hospital or pharmacy], denied on [Date on the denial notice].
My representative may speak and write to the plan about this matter, ask for and receive my claim file, plan documents and records about it, file an appeal for me, ask for external review for me, and receive the plan's notices and decisions.
Please send copies of every notice and decision about this matter to my representative at [Their mailing address or email] and [Their phone number], and also to me.
This letter does not replace [Name of the health plan]'s own authorized representative form. If the plan has its own form, I will complete it, and I ask the plan to treat this letter as a supporting statement. If the plan needs anything else from me or from my representative, please tell us both in writing.
I will tell the plan in writing if I end this authorization.
My signature is below.
Signed: ______________________________ Date: ______________
I accept this role.
Representative's signature: ______________________________ Date: ______________
Enclosures: 1. A copy of the plan's own authorized representative form, completed 2. Copy of the denial letter
Sincerely, [Your name]
Before you send it
Send it to the plan with the plan's own form. Call the member services number on your card, ask for the plan's authorized representative form and where to send it, and write down the date, the person's name and any reference number. Do not guess an address. To prove it arrived, use certified mail with a return receipt, or fax it and keep the confirmation page, or send it through the plan's portal and take a screenshot that shows the date. Give a copy to your representative.
What to enclose
- A copy of the plan's own authorized representative form, completed
- Copy of the denial letter
What happens next
- You: call the plan today and ask for its own authorized representative form. Write down the date and the name of the person you spoke to.
- You and your representative: complete this letter and the plan's form, both signed, and send them together to the plan. Keep copies and the proof of delivery.
- Your representative: phone the plan within a few days to confirm it has both documents and is ready to talk to your representative. Ask for the date the plan recorded.
- You: do not let this wait. Your appeal deadline depends on your coverage and is printed on your denial notice. For most job-based and individual plans it is at least 180 days after you receive the notice. Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different deadlines, often shorter, and they are on your notice. Check the date on your notice, which controls.