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Appointing a Representative

Appointing a Representative – Instructions & Form

People who want to represent a member can be appointed or authorized by the member.

A member can authorize anyone (like a relative, friend, advocate, an attorney, or a doctor) to act as his or her representative and file an appeal or grievance on his or her behalf.

A representative (or surrogate) can also be authorized by the court or act on behalf of the member in accordance with State law to file an appeal or grievance for an enrollee. A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney, or a health care proxy, or a person designated under a health care consent statute.

How to authorize a representative:

  • The member must sign, date, and complete a representative form.
  • The person acting on behalf of the member must sign, date and complete the same form. 
  • Print and complete the Appointment of Representative form below. If a member is incapacitated or legally incompetent a surrogate is not required to submit an Appointment of Representative Form. The surrogate will need to give Buckeye Health Plan copies of the legal papers supporting his or her status as the member’s authorized representative. Buckeye Health Plan requires a copy of the completed and signed Appointment of Representative Form to process an appeal filed by the member’s representative. The form will be valid during the entire appeal/grievance process. The Appointment of Representative Form is valid for one year from the date indicated on the form. A member can revoke the authorization at any time.

Buckeye Health Plan AOR Form (PDF) - Instructions

By clicking on the links below you will be leaving the Buckeye Health Plan website.

Medicare CMS Forms (PDF) - Appointing a Representative- English

Medicare CMS Forms (PDF) - Appointing a Representative-Spanish

An AOR form, along with the members clinicals, can be sent via fax number 866-719-5404