Appointment of Representative

Appointment of Representative Form

When you’re focused on your health, you may need help with everyday affairs. So, you may choose to have a relative, friend, attorney, physician or other advocate serve as your Medicare representative. But, first, you and your representative need to download and fill out an Appointment of Representative form.

The following instructions explain what to do:

How to complete this form

Please print or type. At the top, provide your full name and Medicare number. If you appoint more than one person, you’ll need to fill out a form for each of them.

• Section 1: Appointment of Representative: Give the name and address of the person you’re appointing. You may list one or more persons in an organization, but not the organization itself. Sign and date this section as the “Party Seeking Representation” and provide your street address and phone number.
• Section 2: Acceptance of Appointment: Your representative fills out this section. He or she must give his or her name, sign and date the form, and provide his or her street address and phone number.
• Section 3: Waiver of Fee for Representation: Completing this portion of the form means your representative won’t charge a fee to represent you. If your representative is a health care provider, he or she is required to list your name, sign and date this section.
• Section 4: Waiver of Payment for Items or Services at Issue: If your representative is a health care provider, he or she must sign and date this section. Doing so means you won’t be billed for items or services your plan doesn’t cover if they’re submitted on your behalf.

Where to send this form

Mailing Address:
WYBA Appeals and Grievances
PO Box 21012
Eagan, MN 55121

If your representative will assist you in prescription drug matters with WyoBlue Advantage, mail form to:
Optum
Mail Stop:
6860 West 115th Street
Overland Park, KS 66211-2457