![]() ![]() If an enrollee would like to appoint a person to file a grievance, request a coverage determination, or request an appeal on his or her behalf, the enrollee and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request. Appointment of Representative Form CMS-1696 Included in the " Downloads" section below are links to forms applicable to Part D grievances, coverage determinations (including exceptions) and appeals processes (with the exception of the Appointment of Representative form, which has a link in the "Related Links" section below). This section provides specific information of particular importance to beneficiaries receiving Part D drug benefits through a Part D plan. ![]()
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