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          • Personalized Support for Disease Management
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          • Additional Programs
        • Supporting Caregivers
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        • Managing Diabetes
        • Preventive Care
        • Fall Prevention
        • Chronic Care
        • Flu Prevention
        • Urinary Incontinence
        • Meals and Nutrition
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 1-800-678-2265      TTY 711

7 days a week

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  • Learn More
    • Intro to Medicare
      • Introduction
      • Eligibility and Enrollment
      • Frequently Asked Questions
      • Your Coverage Choices
      • Original Medicare
      • Medicare Advantage
      • Prescription Drug Coverage
      • Plan that’s Right for you
      • Sign-Up for a Guide Book and Email
      • Medicare Basics Video Series
    • Are You Eligible For Medicare?
    • Are Your Drugs Covered?
    • Attend a Seminar
    • About Medicare
      • Important Dates
      • Health Plan Basics
    • Request a Call
  • Health & Wellness
    • Finding Care
      • 24-Hour Nurse Line
      • Care Management
      • ER Alternatives
      • Find a Doctor
      • Mental Health
      • Member Support & Assistance Program
        • In-home Care from Landmark Health
        • In-home Health Assessments with Signify Health®´
        • Personalized Support for Disease Management
        • Health Connect 360SM Program
        • Additional Programs
      • Supporting Caregivers
    • Manage Your Health
      • Managing Diabetes
      • Preventive Care
      • Fall Prevention
      • Chronic Care
      • Flu Prevention
      • Urinary Incontinence
      • Meals and Nutrition
  • Member Resources
    • Plan Information
      • Plan Documents
      • Quality Assurance
      • National Coverage Determination
      • Ending Membership
    • Pharmacy Benefits
      • Drug Benefits
        • Coverage Requirements
        • Formulary Changes
        • Home Delivery
        • Formulary Overview
      • Medicare Advantage Pharmacy Network
      • Medication Therapy Management
      • Prescription Drug Utilization Review
      • Medicare Advantage Pharmacy Network
      • Plan Drug Transition Policy
    • Review Medical Claims
    • Learn to Live
    • Discounts & Programs
    • Appeals & Grievances
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Medicare Advantage Designation of an Authorized Representative

I appoint the individual listed below to act as my representative in connection with my claim, grievance or asserted right under Title XVIII of the Social Security Act (the Act) and related provisions of Title XI of the Act. I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my claim, appeal, grievance or request wholly in my stead. I understand that personal medical information related to my request may be disclosed to the representative indicated below.

The member named below should be the person signing this designation and consenting to the release of information. If the member is a minor, a parent or legal guardian must sign. If the member is unable to sign for any other reason, a legal representative must sign the designation and submit documentation to verify the authority to sign.

*Indicates a required field

Member Information

Enter a three-character prefix, then numerical digits

Authorized Representative Information

Professional status or relationship e.g. child, attorney, etc.

Email

Information That Blue Cross May Disclose


By checking the box below, I grant Blue Cross permission to discuss with or disclose to my authorized representative on my behalf:
I approve the disclosure of the following types of sensitive information by Blue Cross (check all boxes that apply):

Please specify a reason.

Member or Legal Representative Acknowledgement

I understand this designation is valid for 1 year. I may revoke this designation at any time within the year by notifying Blue Cross. I understand that a revocation will not apply to information that was already disclosed. I understand that once information has been disclosed according to these instructions, the Health Insurance Portability and Accountability Act (HIPAA) and other privacy laws may no longer protect the information.

Blue Cross may request information, now or in the future, as it deems necessary to confirm authorized representative status.

Contact Information

If you do have questions, call us at 1-800-200-4255 (TTY: 711).

April 1 through September 30
8:00 a.m. to 8:00 p.m. ET
Monday through Friday

October 1 through March 31
8:00 a.m. to 8:00 p.m. ET
Seven days a week

Blue Cross Blue Shield of Massachusetts is an HMO and PPO Plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities that have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

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Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ®, ℠ Registered and Service Marks of the Blue Cross and Blue Shield Association. ®' Registered Marks of Blue Cross Blue Shield of Massachusetts. ®’’, ℠´, ™ Registered Service and Trade Marks are property of their respective owners. ©   Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

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