How do I designate another person to be my Appointed Representative?

If you want to name a relative, friend, advocate, doctor, or anyone else to act for you as your Appointed Representative to file an appeal or grievance, you and that person will need to complete, sign and date the Appointment of Representative form (or an equivalent form or documentation) showing that the representative you designate is authorized to act on your behalf under state law.

Where do I send my Appointment of Representative Form?

When your Appointment of Representative form is completed and signed by you and the person you designate, please mail it to:

SilverScript Insurance Company
PO BOX 53991
Phoenix, AZ 85072-3991


Return to the Medicare FAQ section to view more answers to other commonly asked questions about Medicare prescription drug coverage.