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Medicare Plans

Appointing/Designating a Representative

Why Appoint a Representative?

You may appoint an individual (such as a relative, friend, advocate, attorney, physician, or an employee of a pharmacy or charity) to act as your representative so that they may file requests for a coverage determination or appeal on your behalf.

How to Appoint a Representative

In order to appoint someone as your representative, you and your representative must sign, date and complete an Appointment of Representative form (CMS-1696). If the appointed representative is an attorney, only the enrollee needs to sign the appointment of representative form or similar statement. Except in the case of an incapacitated or incompetent enrollee, a request for a coverage determination or re-determination from an appointed representative is not valid until supported with an executed appointment of representative form or statement.

Appointment of Representative form (CMS-1696)

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Insurance Disclaimer

Medi-Pak insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Arkansas Blue Cross and Blue Shield is a Medicare-approved Part D sponsor and is a Medicare Advantage organization with a Medicare contract. Enrollment in Medi-Pak Advantage (PFFS) or Medi-Pak Advantage HMO depends on contract renewal.

H4213_PFFS Website 2019
H4213_PFFS Website 2020

CMS Model Electronic Complaint Form

H9699_HMO Website 2019
H9699_HMO Website 2020

Disaster and Emergency Declarations

last updated on 10/01/2019

Medi-Pak Rx (PDP) Plan Information