(Pursuant to 20 2026

1. Click ‘Get Form’ to open it in the editor.
2. In the first section, enter the name of the person appointing a representative. This is crucial for identifying who is granting authority.
3. Fill in your Medicare claim number, Beneficiary Identifier, or plan ID number to ensure proper identification and processing.
4. In the 'Appointment of Representative' section, write the name of the individual you are appointing as your representative. Ensure accuracy as this person will act on your behalf.
5. Sign and date the form where indicated. This confirms your appointment and understanding of the information being shared with your representative.
6. Provide your street address, phone number, city, state, and zip code for contact purposes. An optional email address can also be included.
7. The representative must complete their section by accepting the appointment and providing their professional status or relationship to you.
8. Finally, review all entries for accuracy before submitting. Send this form to the appropriate location as specified in the instructions.

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