Appointment of Representative

Appointment of Representative

Individuals who represent enrollees may either be appointed or authorized.

The Appointment of Representative form is a CMS form that allows a third party to act as your representative when filing a grievance, requesting a determination or in dealing with any levels of the appeals process. The Appointment of Representative form does not give Care1st Cal MediConnect written permission to use/disclose PHI to another company or person (such as a friend or family member). You may mail or fax your completed form to:

Care1st Health Plan
Member Services Department
601 Potrero Grande Drive
Monterey Park, CA 91755

Fax Care1st at 1-323-889-6577

CMS Link to Appointment of Representation form can be found HERE
Or you may also print the CMS'Appointment of Representative form in your preferred language below:

English Spanish