Appointing a Representative

If You Want Someone to Represent You

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.

Who can represent me?

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.

If you don’t want to use the form you may:

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:

• Your full name, mailing address, and phone number
• Your Medicare number or Medicare Beneficiary Identification (MBI)
• Your representatives full name, address, and phone number
• In your statement please include:
  An authorization to release your personal and identifiable health information to your representative
  An explanation why you’re being represented
• Your signature with date
• Your representative’s signature with date

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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