Get Appointment Of Representative - Coventry Medicare

This guide provides clear, step-by-step instructions for completing the Appointment of Representative form for Coventry Medicare online. By following these instructions, you can ensure that you correctly appoint a representative to assist you with your Medicare claims.

Follow the steps to complete the Appointment of Representative form.

1. Click the ‘Get Form’ button to access the Appointment of Representative form. This will allow you to open the document online and begin filling it out.
2. In Section I, enter your name as the beneficiary and your Medicare number. This information is necessary to accurately identify your account and claims.
3. Appoint your representative by entering their name in the designated space. Clearly state that you authorize them to act on your behalf regarding your claims under Medicare.
4. Provide your signature, date, street address, phone number, city, state, and zip code. This verifies your identity and consent for the representative to act on your behalf.
5. In Section II, your appointed representative must acknowledge acceptance by entering their name and professional status or relationship to you. They will also need to sign, date, and provide their contact information.
6. If your representative is waiving their right to charge a fee for their services, they should complete Section III by signing and dating the waiver statement.
7. If applicable, Section IV should be filled out by the provider or supplier regarding services at issue. They must indicate that they waive their right to collect payment for those services.
8. Once all sections are completed and verified for accuracy, you can save your changes. Options to download, print, or share the form will usually be available depending on your online tool.

Take the first step towards efficient Medicare representation by completing your Appointment of Representative form online today.