Appoint a Representative

You or someone you name to act for you (your appointed representative) may request a coverage determination (including exception). You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under state law to act for you.

Please fill out the Appointment of Representative form and send it to us with your request.

AgeWell New York
1991 Marcus Avenue, Suite M107
Lake Success, New York 11042

If you need help filling out the form, or want to learn more about appointing a representative, you can call us at 1-866-237-3210, TTY/TDD members call 1-800-662-1220.

You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services, if you qualify.