Appointing a representative

You have the right to appoint someone to act on your behalf. You can name a relative, friend, advocate, doctor or anyone else to be your appointed representative. This appointed representative may request a coverage determination on your behalf, as well as file a grievance or appeal.

Appointment of Representative form

If you want someone to act as your representative, you and that person must complete an Appointment of Representative form (PDF). 

Instructions for completing the Appointment of Representative form

Please note: You don’t have to appoint your prescribing physician to act on your behalf in requesting an initial coverage determination. 

Enter your name (as beneficiary) and Medicare number in the top two spaces of the form.

Section 1

To be completed by the beneficiary (plan member):

• Enter the name of the individual being appointed
• Sign your name and date the form in Section 1
• Provide your complete address and phone number

Section 2

To be completed by the appointed representative:

• Enter the representative’s name and relationship to the beneficiary
• The representative must sign and date the form in Section 2
• Provide the representative’s complete address and phone number

Section 3

This section should be filled out if the representative waives a fee for such representation. If the representative is a provider or supplier of medical services, he or she must complete this section:

• Enter the beneficiary’s name
• The representative waiving a fee must sign and date the form in Section 3

Section 4

If the person you appoint as a representative is a provider who has already provided services to you, he or she must complete this section waiving the right to charge you for the services. 

• Providers or suppliers serving as a representative for a beneficiary must sign and date the form in Section 4

Mail completed forms to:

Health Alliance Plan/Alliance Health & Life Insurance Co.
Attn: Customer Service Department
1414 E Maple Rd
Troy, MI 48083

Know your medical rights

Unexpected illnesses or accidents can create confusion around important medical decisions. Through a Durable Power of Attorney for Health Care, known in Michigan law as a Patient Advocate Designation, you have the right to appoint a representative to make decisions about your care, custody and medical treatment if you are unable to make those decisions yourself. By doing so now, you can make sure you're prepared in case of an emergency.

To learn more about your medical rights, review our Know Your Medical Rights guide.

Have questions?

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