Harvard Pilgrim Health Care
Appeals & Grievances
P.O. Box 690345
Quincy MA 02269
Or, Fax: (617) 509-3085
Appointment of a Representative
You can appoint a representative to help you file an appeal. Your representative can be a family member, friend, advocate, attorney, doctor or someone else who will act on your behalf. There are two ways to appoint a representative:
- Fill out an Appointment of Representative form.
- Submit a written request with your appeal. Be sure to include:
- Your name, address, phone number, and Medicare number
- A statement appointing someone as your representative
- The name, address, and phone number of your representative
- The professional status of your representative (like a doctor) or their relationship to you
- A statement authorizing the release of your personal and identifiable health information to your representative
- A statement explaining why you’re being represented and to what extent
- Your signature and the date you signed the request
- Your representative's signature and the date they signed the request
At some levels in the appeals process, your doctor or prescriber (for prescription drug appeals) can make a request on your behalf without being appointed as your representative.
If you have questions about appointing a representative, call 1-800-MEDICARE.
You can also call Customer Service at (888) 609-0692 to learn more about how to name your appointed representative. TTY users should call 711. We are open from October 1st to February 14th, from 8 a.m.to 8 p.m., 7 days a week and from February 15th to September 30th, from 8 a.m. to 8 p.m., Monday through Friday.
Last Update 10/01/2017