Get Appointment Of Representation Form - Unison Health Plan Home

Filling out the Appointment Of Representation Form is an essential step for individuals who seek advocacy in their claims under Medicare. This guide will walk you through the process of completing the form online, ensuring you have a clear understanding of each section.

Follow the steps to complete the form effortlessly.

1. Click the ‘Get Form’ button to access the Appointment Of Representation Form and open it in your preferred online editor.
2. In Section I, provide the name of the beneficiary who is appointing a representative. Fill in the beneficiary's Medicare number, and ensure to complete the address, phone number, and date fields accurately.
3. In Section I, the beneficiary must sign their name to indicate acceptance of the representative appointment. The date of signature should be entered as well.
4. Move to Section II, where the appointed representative must write their name and confirm their acceptance of the appointment. It is important to certify that they are not disqualified from acting on behalf of the beneficiary.
5. The representative should indicate their professional status or relationship to the beneficiary in Section II and sign along with the date and their contact information.
6. If applicable, in Section III, the representative must indicate their decision regarding waiving any fees for representation. A signature and date are required here as well.
7. Lastly, if the appeal involves a question of liability under section 1879(a)(2) of the Act, Section IV must be completed. The representative waives their right to collect payment for services and should also sign and date this section.
8. Once all sections are filled out accurately, you can save the changes, download a copy, print the form, or share it as needed.

Complete your Appointment Of Representation Form online today for effective representation in your Medicare claims.