Appointment of Representative Form
CMS Link to Appointment of Representation form HERE.
The Appointment of Representative form is a CMS form that allows a third party to act as your representative when filing a grievance, requesting a determination or in dealing with any levels of the appeals process. The Appointment of Representative form does not give CareMore written permission to use/disclose PHI to another company or person (such as a friend or family member).
Mail completed form to:
Attn: Member Services
12900 Park Plaza Drive, Suite #150
Cerritos, CA 90703
Or Fax completed form to: