Appointing a Representative

If you would like someone other than yourself to file or pursue a grievance or appeal on your behalf, you may appoint a representative to assist you throughout the process.

You may appoint an attorney, a family member, a friend, your caregiver, or another individual you choose to act as your representative.

To appoint a representative, you may complete and submit the appropriate Appointment of Representative Form (CMS-1696) or provide a written request that contains the information required by the form. The appointment must be completed and signed by both you and the individual you are appointing, unless otherwise permitted by applicable requirements.

Your representative may assist you with filing and pursuing a grievance or appeal, communicate with VCC PACE on your behalf, receive information related to your grievance or appeal, and participate in the applicable process.

By appointing a representative, you authorize VCC PACE to communicate with that individual and disclose information necessary to address the grievance or appeal, subject to applicable privacy and confidentiality requirements.

You may appoint a representative at any point during the grievance or appeal process. You may also change or withdraw your appointment in accordance with applicable requirements.

An appointment of representative generally remains valid for one year from the date it is signed, unless it is revoked earlier or otherwise expires under applicable requirements.

If you need assistance completing an Appointment of Representative Form or submitting a written request, please contact VCC PACE.