Fillable Form Approved: STEP 1: Enter information for the (Centers for Medicare & Medicaid Services)

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Form Approved: STEP 1: Enter information for the (Centers for Medicare & Medicaid Services)

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Appoint An Authorized Representative For My Appeal (11/2018)
Appoint an authorized
representative for my appeal
11/2018
Form Approved
Appoint an Authorized
REPRESENTATIVE FOR MY APPEAL
You have the right to choose an authorized representative to help you with an eligibility appeal. This is a trusted person who has your
permission to talk about your appeal with us, see your information, and act for you on matters related to your appeal, including getting
information
about you and signing your appeal request on your behalf. If you want to have an authorized representative, complete and submit this form.
Make a copy for your records and mail the completed form to:
Marketplace Appeals Center
P.O. Box 311
Pittston, PA 18640
You may also fax the form to a secure fax line: 1-877-369-0129.
STEP 1: Enter information for the person who's requesting an appeal (also called an “appellant”).
First name Middle name
Last name Date of birth (mm/dd/yyyy)
Appeal Case ID # (if you have one)
APL
STEP 2: Enter information for the authorized representative.
By appointing an authorized representative, you are requesting that the Marketplace Appeals Center send all communications
(including email or text message reminders) to your representative instead of you.
Authorized representative's first name Middle name
Last name
Mailing address Apartment or suite number
City State ZIP code
Phone number with area code
(
)
Organization name (if applicable)
Page 2 of 2
Appoint An Authorized Representative For My Appeal (11/2018)
STEP 3: Electronic reminders.
If your authorized representative would like to receive electronic reminders about your appeal, please have them provide their
signature below, as well as the preferred method of correspondence (notifications will not contain personal health information).
Get appeal reminders by
Text to mobile number
Mobile number
( )
For electronic reminders privacy information, please visit: healthcare.gov/privacy
Email (Remember to check your spam folder)
Email Address
No reminders
Authorized Representative printed name (if choosing to receive electronic reminders) (First name, Middle name, Last name)
Signature
Date Signed (mm/dd/yyyy)
STEP 4: Signature.
By signing below, you allow the person named in Step 2 to sign your appeal request, get official information about
your appeal, and/or act for you on all future matters related to this appeal.
Appellant printed name (First name, Middle name, Last name)
Signature
Date Signed (mm/dd/yyyy)
To change or remove your authorized representative, or for more information, contact the Marketplace Appeals Center at 1-855-231-1751. TTY
users can call 1-855-739-2231. Our hours of operation are Monday through Friday, 7:00 a.m. to 8:30 p.m. Eastern Time (ET).
You have the right to get the information in this product in an alternate format. You also have the right to file a complaint if you feel you’ve been
discriminated against. Visit cms.gov/About-CMS/Agency-Information/Aboutwebsite/CMSNondiscriminationNotice
, or call the Marketplace
Call Center at 1-800-318-2596 for more information. TTY users can call 1-855-889-4325. If you need assistance in a language other than English, you
have the right to get help and information in your language at no cost. Call the Marketplace Call Center to get information on these services.
Language assistance services
If you need help with your appeal in a language other than English, you have the right to get information in your language at no cost. Call the
Marketplace Appeals Center at 1-855-231-1751. Hours of operation are Monday through Friday, 7:00 a.m. to 8:30 p.m. Eastern Time (ET).
Accessibility
To request appeal forms and notices in an alternate format like braille, large print, data CD, audio CD, or to request a qualified reader, you can call
the Marketplace Appeals Center at 1-855-231-1751. TTY users can call 1-855-739-2231. Hours of operation are Monday through Friday, 7:00 a.m. to
8:30 p.m. Eastern Time (ET). You can also make a request in writing by fax (1-877-360-0130) or mail (Marketplace Appeals Center, P.O. Box 311,
Pittston, PA 18640). Accommodations are provided at no cost to you.
Privacy Act Statement
The Marketplace protects the privacy and security of information about you that you have provided. To view the Privacy Act Statement, go to
Healthcare.gov/individual-privacy-act-statement
. We’re authorized to collect the information on this form and any supporting documentation,
including Social Security numbers, under the Patient Protection and Affordable Care Act (Public Law No. 111–148), as amended by the Health Care
and Education Reconciliation Act of 2010 (Public Law No. 111–152), implementing regulations in 45 CFR part 155, subpart F, and the Social Security
Act. For more information about the privacy and security of your information, visit healthCare.gov/privacy
.
Nondiscrimination
The Health Insurance Marketplace doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color,
national origin, disability, sex, or age. If you think you’ve been discriminated against or treated unfairly for any of these reasons, you can file a
complaint with the Department of Health and Human Services, Office for Civil Rights by calling 1-800-368-1019 (TTY: 1-800-537-7697), visiting
hhs.gov/ocr/civilrights/complaints
, or writing to the Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence
Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201.
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Form Approved: STEP 1: Enter information for the (Centers for Medicare & Medicaid Services)

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Completed 19 July 2020

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