Complete this form if you want us to work with your representative on an initial request for coverage, a grievance or appeal.
It’s important to know:
- We can only talk to your representative about a request for coverage, grievance or appeal with this form. To talk to us about other things, complete the form above.
- Your doctor or other prescriber can make a coverage request and file certain appeals without being your representative.
We’re here to help. If you have a question or concern, you can call us at the number on your member ID card.
You'll leave Aetna Medicare and go to the CMS website if you link to the form.
Appointment of Representative CMS Form
Appointment of Representative CMS Form (Spanish)
If you don’t want to use the form, you can write a letter. We’ll accept your letter if both you and your representative sign and date it. Your letter must include all of the following:
- Your Medicare Health Insurance Claim Number (HICN) or Medicare ID number
- Your name, address and phone number
- Your representative’s name, address and phone number
- A statement that allows your representative to act on your behalf and allows us to give your personal information to your representative
- A statement that your representative is willing to act on your behalf
Mail the form or letter to the same location as your request for coverage, appeal or complaint. You can call us with your questions at the number on your ID card.
