Brand New Day is not allowed to speak with others about your membership, your health status, your care, or any other private matter unless you ask us to do so. If you want someone else to speak and make decisions for you, please complete the Appointment of Representation Form described below and mail or fax it to Brand New Day.
There may be someone who is already legally authorized to act as your representative under state law. Please provide a copy of the authorization for representation to Brand New Day by mail or fax.
You can appoint a friend or relative, your doctor or other person to be your representative.
Write a letter telling us that you want to appoint a representative. Be sure to keep a copy of your letter or CMS Form 1696 Appointment of Representation (English) (Spanish).
Include the following information:
REMINDER: Please include your Authorization of Representation form with each Appeal you submit. Visit File an Appeal for additional information on how to file an appeal.
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