(Print the name and address of the person or entity allowed to act on your behalf.) to be my Authorized Representative for the service noted above. That means ...

Form 216-B. (7/11). APPOINTMENT OF AUTHORIZED REPRESENTATIVE. Complete this section only if someone other than the covered person is appealing. The ...

Appointment of Representative Form* Use when you want someone other than yourself to stand for you in all matters that have to do with your coverage ...

You may represent yourself, or you may ask another person, including your treating health care provider, to act as your authorized representative. You may ...

A Personal Representative may either be legally appointed or designated by a Customer to act on his or her behalf: • When a Personal Representative has been ...

4 дня назад · Behavioral Appointment of Representative Form: English [PDF]. Behavioral Appointment of Representative Form (fillable version): English [PDF].

Section 1: Appointment of Representative. To be completed by the party seeking representation (i.e., the Medicare beneficiary, the provider or the supplier):.

Attach a completed Authorization of Representation form CMS-1696 or a written equivalent. The CMS-1696 Form can be located here: Appointment of Representative ( ...

Form #. CMS 1696 ; Form Title. APPOINTMENT OF REPRESENTATIVE ; Revision Date. 2021-09-01 ; O.M.B. #. 0938-0950 ; O.M.B. Expiration Date. 2024-09-30.

Cigna Appointment of Representative Form. Check out how easy it is to complete and eSign documents online using fillable templates and a powerful editor.