Appointment of representative

Especially in cases of incompetence or incapacity, providers must determine if the member has completed some kind of written documentation appointing a representative (AOR) prior to providing services to the member or admitting the member to a hospital or other facility. This documentation identifies the member's health care proxy.

Evidence of such an appointment in the medical record could include the CMS-1696 Appointment of Representative form or equivalent written notice. An "equivalent written notice" is described in #1384, Appointment of Representative Procedure as well as in Section 10.4.1, Chapter 13, Medicare Managed Care Manual.

Standard CMS forms

Appointment of Representative (English)

Nombramiento de un Representante (Español)

No AOR on file

For situations in which there is no AOR, the following guidance applies.

Notify the family:

Even though family members may assert they are not responsible for the member or do not wish to accept or sign a Notice of Medicare Non-coverage (NOMNC) or other notice of coverage or financial responsibility, this is not sufficient reason to not deliver the notice. The notice can be given in writing directly to the family representative or by phone.

Suggested statement and documentation when giving a Notice of Medicare Non-coverage (NOMNC):

[Name of facility or agency] is providing this notice of termination of services as of [give date] on behalf of [name of member]. Services provided on or after [give date when services end] will be the responsibility of your relative. The notice contains information on how your relative may appeal this decision.

No family:

In the situations below and others where there is no family, a NOMNC should be kept in the member's medical record at the Skilled Nursing Facility, together with notification that Priority Health will not cover room/board but, if medically necessary, will cover those services that are covered by Part B Medicare. The facility or agency retains the notice in the member's record. 

  • Guardianship pending: Waiting for guardianship proceedings to conclude is not sufficient reason to delay the notice.
  • Finding a safe place for the member to stay: Delays to the date the member leaves the facility are not sufficient reason to delay the notice.