Appointment of Representative

As a member of Leon Health, you have the right to select someone other than yourself to file a complaint or appeal on your behalf. You may do so by completing an appointment of representative form and send the form to the plan. You must make sure that the appointment of representative form is completed in its entirety and must include the following information:

  1. Your Medicare number. Print or type your number and your name on the top of the form.
  2. Appointment of at least one person to act on your behalf. You can name more than one. If you do, you may want to complete a form for each of them.
  3. Each person you appoint needs to complete the Acceptance of Appointment section. They provide their names and state where they accept the appointment
  4. The person or people you name should fill out the Waiver of Fee for Representation part of the form if he or she won’t charge you for acting on your behalf.

Note: A Durable Power of Attorney agreement can be used in place of an Appointment of Representative form. That means you don’t have to fill out an Appointment of Representative form if they have a Durable Power of Attorney agreement in place.

You can find our appointment of representation form here:
Download Appointment of Representative Form

And if you need help in complete the form, please contact our Member Services Department at 844-9-MY-LEON (1-844-969-5366) or local at 305-541-LEON (305-541-5366) for any questions. (TTY users should call 711).

Hours are from 8 a.m. to 8 p.m., seven days a week from October 1st through March 31st and Monday through Friday from April 1st through September 30th.

Ready to Enroll with LEON Health?

As you prepare for Medicare, you’ll be faced with many important decisions. LEON Health wants to help you select the best options for your needs.

Enroll Today