To fill out an Appoint an Authorized Representative for My Appeal Form online, you’ll need to download it onto your computer first.
Step 1: Download the Appoint an Authorized Representative for My Appeal Form
Right click on this Appoint an Authorized Representative for My Appeal Form (PDF, 585 KB).
Step 2: Save the form on your computer
- Download the form on your computer
- Chrome and Firefox users: Choose "Save Link As…"
- Microsoft Edge users: Choose "Save Target As…"
- Safari users: Choose "Download Linked File as…"
- Select a location on your computer to save this application – on the desktop, in your documents folder, or somewhere else it will be easy to find.
- Click Save.
Step 3: Open the form and fill it out
When you’re ready to fill out the Appoint an Authorized Representative for My Appeal Form (PDF):
- Minimize this web browser window
- Locate the Appoint an Authorized Representative for My Appeal Form (PDF) you downloaded to your computer in Step 2.
- Click on the document to open it. You’re ready to start filling it out.
- When you’ve finished filling out the form, save it, print it, and mail it, or fax it to the Health Insurance Marketplace® at the location shown on the form.