Appointment of Representative

You may appoint an individual to act as your representative. With your written authorization, the appointed individual can do the following on your behalf:

  • Make any request, such as file a grievance or an appeal, on your behalf.
  • Present or gather evidence
  • Obtain appeals information
  • Receive any notice in connection with an appeal

A signed authorization form is required by Medicare for an individual to make some requests from Banner Medicare.

To request an Appointment of Representative (AOR) Form, please call our Customer Care Center at (844) 549-1859, TTY 711.

OR print out the form listed below. The form must be signed by you and by the person who you would like to act on your behalf. You must also give us a copy of the signed AOR form.

Related Forms

Appointment of Representative Form     English | Español