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 Zing Health Member Designated Representative Form which you may use for appointment of representative

You may also use an equivalent written notice. An equivalent written notice includes the following:

• 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 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 by fax or by mail to

Zing Health
Appeals and Grievances Department
P.O. Box 1222
Chicago, IL 60606

Fax: 1-844-946-4468

If you have any questions, we ask you to first call customer service at 1-866-946-4458 (TTY: 711).