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Forms for Appointing a Representative

A member can choose someone else, such as a family member, doctor or attorney, to represent you when interacting with CareFirst BlueCross BlueShield Medicare Advantage. To appoint a representative, you must fill out one of these two forms. Please note the differences between them and choose the one that best suits your needs.

CareFirst Designation of Personal Representative Form

Using this form allows your designated representative to act on your behalf in all matters regarding CareFirst BlueCross BlueShield Medicare Advantage. It grants your representative the ability to make decisions related to your healthcare with the same rights and privileges afforded to you as a plan member. This form has no set time limit. It’s valid until you revoke your representative’s authority.

Once completed, send the form to:

CareFirst BlueCross BlueShield
Privacy Office
P.O. Box 14858
Lexington, KY 40512

Email: privacy.office@carefirst.com
Fax to: 410-505-6692

CMS Appointment of Representative Form

Using this form gives your appointed representative a limited ability to act as your representative with CareFirst BlueCross BlueShield Medicare Advantage. Your representative’s authority is limited to claims, coverage decisions, appeals and grievances. In addition, the form is only valid for one year.

Once completed, send the form to:

CareFirst BlueCross BlueShield
Privacy Office
P.O. Box 14858
Lexington, KY 40512

Email: privacy.office@carefirst.com
Fax to: 410-505-6692

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