Authorized Representative

As a Medicare beneficiary, you have the right to appoint a representative to act on your behalf. An appointed representative can be a relative, friend, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

To appoint a representative, you and your appointed representative need to complete the Appointment of Representative Form and sign where indicated. Please click the Appointment of Representative Form (CMS-1696) link below to access this form. Once you have printed, completed and signed the form, please mail it to the following address:

Meridian Medicare-Medicaid Plan
P. O. Box 3060
Farmington, MO 63640-3822

• Appointment of Representative Form (CMS-1696) October 1, 2023
• Appointment of Representative Form (CMS-1696) - Spanish October 1, 2023

Review information on Advance Directives
Examina la informaciòn sobre las directivas anticipadas

As a Medicare beneficiary, you have the right to appoint a representative to act on your behalf. An appointed representative can be a relative, friend, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

To appoint a representative, you and your appointed representative need to complete the Appointment of Representative Form and sign where indicated. Please click the Appointment of Representative Form (CMS-1696) link below to access this form. Once you have printed, completed and signed the form, please mail it to the following address:

Meridian Medicare-Medicaid Plan
P. O. Box 3060
Farmington, MO 63640-3822

• Appointment of Representative Form (CMS-1696)
• Appointment of Representative Form (CMS-1696) - Spanish version

Review information on Advance Directives
Examina la informaciòn sobre las directivas anticipadas