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How to use or fill out the Appointment of Representative form
- Click ‘Get Form’ to open it in the editor.
- In Section I, enter your name and Medicare or National Provider Identifier Number. Appoint your representative by filling in their name and providing your signature along with the date, address, and phone number.
- Move to Section II where your representative must accept the appointment. They should fill in their name, professional status, and provide their signature and date.
- If applicable, complete Section III to waive any fees for representation. The representative must sign and date this section.
- Finally, if relevant, fill out Section IV regarding the waiver of payment for items or services at issue. Ensure all signatures are provided before submission.
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