Appointment of Representative

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Auth Specialist
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vid
Name of Party*
Medicare Number*
Section I: Appointment of Representative
To be completed by the party seeking representation (i.e., the Medicare beneficiary, the provider or the supplier):
I appoint this individual, {auth_specialist}, to act as my representative in connection with my claim or asserted right under Title XVIII of the Social Security Act (the Act) and related provisions of Title XI of the Act. I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my claim, appeal, grievance or request wholly in my stead. I understand that personal medical information related to my request may be disclosed to the representative indicated below.
Signature
Date*
MM slash DD slash YYYY
Address*
Phone*
City*
State*
Zip*
Email

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Section I: Appointment of Representative