Appointment of Representative

You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.

You and the person you choose must sign, date, and complete a representative statement (see link to form below). A request may also be made in a written letter. If you are legally not of sound mind or are incapacitated, the representative can complete and sign the statement. The representative needs to have the appropriate legal papers or legal authority to sign for you. If you choose a lawyer, only you need to sign the representative statement.

The representative statement must include your name and Medicare number. You can use Form CMS-1696-U4 (see link to form below) or SSA-1696-U4, Appointment of Representative. You can also find this form at Social Security offices, although it is not required.

CMS Appointment of Representative Form