Naming someone to help you with an exception

In some cases, you may need another person to represent your exception or grievance.

How to name someone to help you

If you want someone else, like a family member or friend, to act for you when you make a Grievance or appeal a decision, you can sign a form that makes that person your official "authorized representative." Here's how:

1. Print a Medicare Appointment of Representative form from the CMS website.
2. Write in the name of the person you want to act for you. Sign and date the form.
3. Have your representative sign and date the form.
4. Mail the form to us at:
   Priority Health Medicare Appeals
   1231 East Beltline NE, MS 1150
   Grand Rapids, MI 49525

You can also deliver it in person at these locations, or fax it to us at 616.975.8827, or call Customer Service.