CareMore Cal MediConnect

Member Authorization Forms

Member Authorization Form

If a member wants give CareMore written permission to use/disclose PHI to another company or person (such as a friend or family member), please complete the Member Authorization Form.

Member Authorization Form (PDF)

Appointing a representative

Your doctor or other provider can ask for a coverage decision or an appeal on your behalf. They do not need to complete the Appointment of Representative form to do this.

You can also name another person to represent you. This person can be your:

They can ask for a coverage decision, an appeal or a complaint on your behalf.

The court may approve, as allowed by state law, a person to represent you to act on behalf of you. This representative is referred to as a surrogate.  A surrogate can be any of the following:

  • A guardian assigned by the court
  • A person who has a Durable Power of Attorney
  • A health care proxy
  • A person who is chosen under  a health care consent law

Due to your disability or inability to legally make decisions a surrogate does not have to produce a representative form.  Instead he or she must produce other legal papers that prove that he or she is authorized to be your representative.

Call Member Services to ask for the "Appointment of Representative" form. You can also get the form on the Medicare website at http://www.cms.gov/cmsforms/downloads/cms1696.pdf. You must complete and submit the form to give the person permission to act for you. You can also send a written statement instead of the form. It must be signed and dated by both you and your representative. The statement must include:

  • Your name, address, phone number and member ID number
  • Your Health Insurance Case Number (HICN) or Medicare Identifier (ID) Number
  • Your representative's name, address and phone number
  • A statement giving the person you choose permission to represent you
    • Example: "I, [insert your name,] give permission to [insert the name of your representative] to ask on my behalf for an appeal from CareMore and/or CMS about the denial or discontinuation of medical services."
  • Your signature and date
  • The signature of the person who will represent you, their agreement to represent you and the date they agreed to represent you.

Your request must include a copy of the signed form or a written statement.

CMS Link to Appointment of Representation form HERE.

Mail completed form to:

CareMore
Attn: Member Services
12900 Park Plaza Drive, Suite #150
MS-6150
Cerritos, CA 90703

Or Fax completed form to 1-888-426-5087