Appoint a Representative

Choose someone to act on your behalf

You can choose someone to act on your behalf. To protect your privacy, we have different forms to complete, based on what you want your representative to do for you.

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Authorization for Release of Protected Health Information (PHI): Complete this form if you want us to talk with your representative about:

Your benefits and coverage

Your claims

Your bills

It’s important to know:

The PHI form doesn’t override Power of Attorney documents. You don’t need to complete the PHI form if you have a Power of Attorney (POA).

The PHI form is only good for one year. You need to complete a new form each year for a representative to continue to assist you.

You need to complete a separate form (see below), if you need help filing an initial request for coverage, a grievance or appeal.

Return the completed form to us at the address or fax number shown on the form.

Open and print the PHI release form
Open and print the PHI release form (Spanish)
Medicare’s form to assist with initial requests for coverage, grievances and appeals: Complete this form if you want us to work with your representative on an initial request for coverage, a grievance or appeal.

It’s important to know:

We can only talk to your representative about a request for coverage, grievance or appeal with this form. To talk to us about other things, complete the form above.

Your doctor or other prescriber can make a coverage request and file certain appeals without being your representative.

We’re here to help. If you have a question or concern, you can call us at the number on your member ID card.

You'll leave Coventry Medicare and go to the CMS website if you link to the form.

Appointment of Representative CMS Form
Appointment of Representative CMS Form (Spanish)

If you don’t want to use the form, you can write a letter. We’ll accept your letter if both you and your representative sign and date it. Your letter must include all of the following:

Your Medicare Health Insurance Claim Number (HICN) or Medicare ID number

Your name, address and phone number

Your representative’s name, address and phone number

A statement that allows your representative to act on your behalf and allows us to give your personal information to your representative

A statement that your representative is willing to act on your behalf

Mail the form or letter to the same location as your request for coverage, appeal or complaint. You can call us with your questions at the number on your ID card.

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Authorization for Release of Protected Health Information (PHI)

Medicare’s form to assist with initial requests for coverage, grievances and appeals

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