McLaren Medicare
Appoint a Representative

How to Appoint a Representative

You have the right to have someone act on your behalf when you need help with filing an appeal or grievance or when making a coverage request. This person is called your appointed representative. Your appointed representative can be a relative, friend, or any other person you want to file an appeal or grievance or submit a coverage request for you.

To name someone to be your appointed representative, you must fill out and sign an Appointment of Representative form or provide us with the equivalent information. To get the form call Member Services at 833-358-2404 (TTY: 711) and ask for the Appointment of Representative form or download and print the Appointment of Representative form from the Medicare website.

Once you have the form, you must complete it and both you and your appointed representative must sign. Completed, signed forms are valid for one year or for the duration of the individual appeal, grievance or coverage request if longer than one year.

You can mail the completed form to:

McLaren Medicare
Attn: Appeals & Grievances
PO Box 44092
Indianapolis IN 46244-0092