Members Resources

Find tools, information, and other resources to help you get the most out of your benefits.

Appoint a Representative

You or someone you name may file a complaint (grievance) or appeal for you. The person you name would be your “appointed representative”. You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act on your behalf.

To appoint a representative, fill out CMS Appointment of Representative Form (CMS Form-1696).

Once you have filled out the form, you may print and mail the form to:

Perennial Advantage
Appeals and Grievances Department
PO Box 2190
Glen Allen, VA 23058

You may also send a fax to 1-833-610-2380

For a description of, and information on how to appoint a representative, you may also call Member Services at 1-844-788-6959 ( TTY 711) for Colorado and 1-844-788-6986 (TTY 711) for Ohio.