Appointing a Representative
You have the right to appoint someone to act on your behalf. You may name a relative, friend, advocate, doctor, or anyone else to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative.
The representative statement must include your name and Medicare number. You may use Form CMS-1696 (PDF). You may also use an equivalent notice which satisfies the requirements in Form CMS-1696.
Unless otherwise stated, your appointed representative will have all of your rights and responsibilities when acting on your behalf.
For additional information on how to name your appointed representative, you may call Customer Care toll-free at 1-877-883-9577 (TTY/TDD 1-800-662-1220) 8 a.m. to 8 p.m., Monday – Friday. From Oct. 1 to Mar. 31, representatives will be available seven days a week from 8 a.m. to 8 p.m.
Simply Prescriptions contracts with the Federal Government and is a PDP plan with a Medicare contract. Enrollment in Simply Prescriptions depends on contract renewal. Submit feedback about your Medicare prescription drug plan at www.Medicare.gov or by contacting the Medicare Ombudsman. _.
This page last updated 10-01-2023.
