If someone other than the plan member wants to file a grievance or an appeal, appropriate documentation is required. Appropriate documentation may include, but is not limited to, a durable power of attorney, a health care proxy, an appointment of guardianship or other legally recognized forms of appointment, or an Appointment of Representative form. If the appealing party is a non-contracted provider, a Waiver of Liability form must be executed.

Click Here to access the Appointment of Representative form, print, and follow these instructions.

Section 1: APPOINTMENT OF REPRESENTATIVE
To be filled out by member: Fill in the name of the person you want to represent you in your grievance or appeal. Sign and date at the end of this section.

Section 2: ACCEPTANCE OF APPOINTMENT
To be filled out by the appointed representative: Appointed representative fills in his/her name and relationship to the member. Appointed representative will sign and date at the end of this section.

Section 3: WAIVER OF FEE FOR REPRESENTATION
To be filled out by appointed representative: (if applicable) If an appointed representative is waiving a fee for representing the member, this section should be completed.

Section 4: WAIVER OF PAYMENT FOR ITEMS OR SERVICES AT ISSUE
To be filled out by a non-contracted provider who is appealing a denied payment or service if the appeal involves a question of liability. Non-contracted provider will waive the right to collect payment from the member for items or services at issue.

For members and physicians who have questions about the appointment of representative process, please contact PrimeTime Health Plan Member Services at: Telephone: (330) 363-7407, toll-free: 1-800-577-5084 TTY: (330) 580-6460 or 1-800-617-7446

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