What is an AOR for Medicare?

If you want to let someone represent you in a Medicare appeal or grievance, use this form. Do you need someone to file a complaint or appeal for you? If so, this document allows you to name someone to make decisions for you. This person is often a relative, friend, lawyer or doctor.

What is an example of an authorized representative?

The most common example of an authorized representative is a person acting on behalf of a company. What is this? For instance, if a company CEO or President signs a document on behalf of the company, that person is the authorized representative of the company.

What makes someone an authorized representative?

Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.

What does signature of authorized representative mean?

If the represented person is bound, the signature of the representative is the authorized signature of the represented person and the represented person is liable on the instrument, whether or not identified in the instrument.

What is the CMS definition of authorized representative?

Medicare beneficiaries have the right to choose someone to help make decisions about Medicare coverage. This is referred to as an Authorized Representative. This person is only authorized to help with Medicare joining a plan, quitting a plan, finding out information about insurance and handling claims and payments.

Can you have more than one authorized representative?

Yes. There is no limit to how many Authorized Representatives you can have, but you must submit a separate form for each person you appoint as an Authorized Representative. Can I have an organization act as my Authorized Representative?

What is an authorization of representation?

As the authorized representative, you have the ability to receive correspondence, submit additional evidence, argue factual or legal issues and exercise appeal rights pertaining to the above claim. An authorized representative does not have signature authority on behalf of the claimant on Form EN-20.

What is the other name for Aetna?

Coventry Health Care. Healthagen. Active Health Management. Aetna International. First Health PPO Network.

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Aetna Authorized Representative Designation 2007

Get Aetna Authorized Representative Designation 2007-2024

From Aetna IMPORTANT Your signature below means that you understand and agree to the following In conjunction with this appeal Aetna may disclose Protected Health Information PHI to the abovenamed authorized representative Representative. Aetna Federal Plans P. O Box 550 Blue Bell PA 19422 Fax 215-775-5246 AUTHORIZED REPRESENTATIVE DESIGNATION Member Name Aetna ID No. Provider of Service Name and dates of service or proposed service I do hereby name to act as my authorized representative in requesting regarding the above-noted service or proposed service. The PHI disclosed pursuant to this authorization may include diagnosis and treatment information including information pertaining to chronic diseases behavioral health conditions alcohol or substance abuse communicable diseases sexually-transmitted diseases HIV/AIDS and/or genetic marker information* Information disclosed pursuant to this authorization may be redisclosed by the Representative and may no longer be protected by federal or state privacy regulations. If you would like to pursue an appeal at the Representative s request but do not want the Representative to receive any PHI or other information related to the appeal including the appeal decision you may indicate that choice by checking the box on the signature line below. Your ability to enroll in an Aetna plan and your eligibility for benefits and payment for services will not be affected if you do not sign this form* However without your signature we cannot process the appeal initiated by the Representative. This authorization is only valid for the duration of the appeal* If you sign this form you may revoke the authorization at any time by notifying Aetna in writing at the address above. Revoking this authorization will not have any effect on actions that Aetna took in reliance on the authorization before we received the notification* Please accept this appeal from my representative on my behalf however forward all information related to this appeal including the appeal decision and any request you may have for additional information to my attention only. Signature Date Print Name If person signing this Authorization is not the Member describe relationship to the Member i*e* Parent Legal Representative Legal Representatives signing this authorization on behalf of a Member must furnish a copy of a health care power of attorney or other relevant document that grants the applicable legal authority. The PHI disclosed pursuant to this authorization may include diagnosis and treatment information including information pertaining to chronic diseases behavioral health conditions alcohol or substance abuse communicable diseases sexually-transmitted diseases HIV/AIDS and/or genetic marker information* Information disclosed pursuant to this authorization may be redisclosed by the Representative and may no longer be protected by federal or state privacy regulations. If you would like to pursue an appeal at the Representative s request but do not want the Representative to receive any PHI or other information related to the appeal including the appeal decision you may indicate that choice by checking the box on the signature line below. .

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