Appointing a Representative
If you need someone to file a grievance, coverage determination, or appeal on your behalf, you can name a relative, friend, advocate, doctor, or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.
If you are requesting a coverage determination through an appointed representative, you should download form CMS-1696 (pdf)*, complete it, and mail it to:
Commonwealth Care Alliance
30 Winter Street
Boston, MA 02108
Fax: (617) 426-1311
If you have any questions about naming your appointed representative, you can call us at 1‑866‑610‑2273 (TTY 711).
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Last Updated 07/29/2013