Appointment of Representative
You may choose someone to act on your behalf. You may choose a relative, friend, sponsor,
lawyer or a doctor. A court may also appoint someone. You and the person you choose must
sign, date, and complete a representative statement.
Zing Health does not require a specific form for appointments. Zing Health can provide the
CMS Appointment of Representative Form - CMS-1696 which you may use for appointment of
You may also use an equivalent written notice. An equivalent written notice includes the
- Name, address, and telephone numbers of the member and the individual being appointed;
- Your HICN or Medicare Beneficiary Identifier, or plan ID number;
- The appointed representative’s professional status or relationship to the you;
- A written explanation of the purpose and scope of the representation;
- A statement that you are authorizing the representative to act on your behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to the representative;
- A statement by the individual being appointed that he or she accepts the appointment; and
- Is signed and dated by you and the individual being appointed.
A representative form is valid for one year from the date it has signatures for both you and the
appointee, unless revoked. For example, if the enrollee signs the form on January 1, 2020 and
the representative signs on January 3, 2020 (or vice versa), the form is effective for one year
starting on January 3, 2020.
If the you would like the same individual to continue serving as a representative after one year,
you must reappoint that person by submitting a new representative form.