Authorized Representative

Appointing a Representative – Instructions & Form

A member can give okay to another adult person (like a relative, friend, lawyer or doctor) to act as his or her representative to file a complaint or appeal or to request a coverage determination on his or her behalf.

A representative can also be approved by the court or act on behalf of the member to file an appeal or complaint on their behalf. A representative can include, but is not limited to, a court ordered guardian, a person who has Durable Power of Attorney, a health care proxy or a person chosen under a health care consent statute.

If a member is incapacitated or legally incompetent a representative is not required to submit a CMS-1696 Appointment of Representative Form (PDF). The representative will need to give Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) copies of the legal papers supporting his or her status as the member’s authorized representative.

How to Authorize a Representative:

• The member must sign, date and fill out a representative form.
• The person acting on behalf of the member must sign, date and fill out the same form.
• Download the CMS-1696 Appointment of Representative Form (PDF), complete it and mail it to:

Part C (and Part B Drugs) Appeals, and Part C and D Grievances:
Superior STAR+PLUS MMP
Appeals & Grievances
Medicare Operations
7700 Forsyth Blvd.
St. Louis, MO 63105

Fax: 1-844-273-2671

Part D Appeals:
Superior STAR+PLUS MMP
Medicare Part D Appeals
P.O. Box 31383
Tampa, FL  33631-3383

Fax: 1-866-388-1766

Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) requires a copy of the completed and signed CMS-1696 Appointment of Representative Form (PDF) to move forward with appeals or complaints filed by the member’s representative.

• The form will be valid during the entire appeal or complaint process.
• The Appointment of Representative (AOR) Form (PDF) is valid for one year from the date on the form. A member can cancel the Form at any time.

Appointing a Representative – Instructions & Form

A member can give okay to another adult person (like a relative, friend, lawyer or doctor) to act as his or her representative to file a complaint or appeal or to request a coverage determination on his or her behalf.

A representative can also be approved by the court or act on behalf of the member to file an appeal or complaint on their behalf. A representative can include, but is not limited to, a court ordered guardian, a person who has Durable Power of Attorney, a health care proxy or a person chosen under a health care consent statute.

If a member is incapacitated or legally incompetent a representative is not required to submit a CMS-1696 Appointment of Representative Form (PDF). The representative will need to give Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) copies of the legal papers supporting his or her status as the member’s authorized representative.

How to Authorize a Representative:

• The member must sign, date and fill out a representative form.
• The person acting on behalf of the member must sign, date and fill out the same form.
• Download the CMS-1696 Appointment of Representative Form (PDF), complete it and mail it to:

Part C (and Part B Drugs) Appeals, and Part C and D Grievances:
Superior STAR+PLUS MMP
Appeals & Grievances
Medicare Operations
7700 Forsyth Blvd.
St. Louis, MO 63105

Fax: 1-844-273-2671

Part D Appeals:
Superior STAR+PLUS MMP
Medicare Part D Appeals
P.O. Box 31383
Tampa, FL  33631-3383

Fax: 1-866-388-1766

Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) requires a copy of the completed and signed CMS-1696 Appointment of Representative Form (PDF) to move forward with appeals or complaints filed by the member’s representative.

• The form will be valid during the entire appeal or complaint process.
• The Appointment of Representative (AOR) Form (PDF) is valid for one year from the date on the form. A member can cancel the Form at any time.