Get IL Appointment Of Authorized Representative Form 2020-2024

Appointment of Authorized Representative (Purpose: To grant permission for another individual or company to act on your behalf in filing a Grievance or Appeal).

What is an Authorized Representative? An Authorized Representative is someone you can name and give access to your Protected Health Information (PHI). An Authorized Representative can be family members, friends, or any other individual you choose.

The Centers for Medicare & Medicaid Services (CMS) is a Federal agency within the U.S. Department of Health and Human Services. Many CMS program related forms are available in Portable Document Format (pdf).

Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person.

A party may revoke an appointment of representative at any time. The revocation becomes effective when the ALJ receives a signed, written statement of the revocation from the party. The death of a party terminates the authority of the appointed representative.

You can use the Appointment of Representative (AOR) form CMS-1696* or you can make your own statement (an equivalent written notice) as long as it contains all the required information. In addition, we may also accept other forms of legal documentation.

To appoint a representative, you or your representative should complete the form entitled: Appointment of Representative - CMS-1696 - PDF.

The Centers for Medicare & Medicaid Services, CMS, is part of the Department of Health and Human Services (HHS).