_________________________________________________________________________
HHS Federal External Review Process
Appointment of Representative Form
Please return this signed and completed form to the following address:
HHS Federal Ex
ternal Review Process
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
Section 1: APPOINTMENT OF REPRESENTATIVE
NAME OF CLAIMANT PLAN\INSURANCE IDENTIFICATION NUMBER
To be completed by the claimant:
I appoint this individual:__________________________________ to act as my representative in
co
nnection with my request for external review by the HHS Federal External Review Process. I
authorize this individual to make any request; to present or to produce evidence; to obtain external
review information; and to receive any notice in connection with my external review, wholly in my
place. I understand that personal medical information related to my appeal may be disclosed to the
representative indicated below.
SIGNATURE OF CLAIMANT DATE
STREET ADDRESS PHONE NUMBER
CITY STATE ZIP
Section 2: ACCEPTANCE OF APPOINTMENT
To be completed by the representative:
I, __________________________________ hereby accept t
he above appointment. I certify that I
have not been disqualified, suspended, or prohibited from practice before the Department of Health
and Human Services; and that I am not, as a current or former employee of the United States,
disqualified from acting as the claimant’s representative.
I am
a / an
(Professional Status Or Relationship To The Claimant, E.G., Attorney, Relative, Etc.)
SIGNATURE OF REPRESENTATIVE DATE
STREET ADDRESS PHONE NUMBER
CITY STATE ZIP
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