Health Choice Generations
Text Size: Smaller Font Larger Font Reset Font  
Click to Expand Members
Introduction About Us About Medicare Member Registration Member Services Medical Services Member Newsletters Cultural Competency Community Resources and Links Behavioral Health Connections Frequently Asked Questions What's New
Click to Expand Providers
Appeals Provider Log-In/Sign-Up Provider Manual Network Services MedSolutions Benefits and Covered Services Commonly Used Forms Fraud Waste and Abuse Provider Resources and Links Multi-Cultural Resources Why Join HC Generations? National Provider Identifier Claim Information and Updates Important Notices for Providers DRA Training
Click to Expand Medicare Part D Plans
What is Part D Why join HC Generations HC Generations Drug Coverage Denies Coverage for a Prescription Drug Drug Formulary Guide Formulary Change Notice Grievances and Appeals Coverage Determination / Coverage Re-determination Prior Authorization Mail-order Program Medication Therapy Management Program Plan Transition Process Plan Ratings
Click to Expand Members Need to Know
Rights and Responsibilities Fraud and Abuse Grievances and Appeals
Appointment of Representative
Advance Directives
Click to Expand Health Education
Introduction Diabetic Education Depression Ready, Set, Quit! Be Smart, Get Active Phone Scams Protect your Identification Dog Days of Summer UV Safety Safe Swimming Tips Preventative Care and Screening Tips Behavioral Health Connections Safe Stay Strategies
Health Choice Arizona
Click to go to KPHO website
Most of the documents posted on the Health Choice Generations' Web sites are available for viewing or printing in Adobe PDF format. If you do not have Adobe Reader installed, please download from here for free:
 
Appointment of Representative

Sometimes, people need assistance to help them make decisions, ask questions or to help them interpret the rules and regulations of a plan. If this happens, you have the right to ask someone such as a family member or friend to help you with decisions about your healthcare. There is a special form called an "Appointment of Representative" to give someone you trust the legal authority to make decisions for you about claims, organization determinations, reconsiderations, other appeals and grievances, should you be unable to make decisions for yourself.

If you decide that you want to appoint someone to speak on your behalf, please fill out the form below and return to Health Choice Generations by either faxing to (480) 784-2933 or by mail to: Health Choice Generations, 410 N. 44th Street Suite. 900 Phoenix, AZ 85008.

NOTE: Please make sure you make a copy and retain for your records before mailing or faxing to Health Choice Generations.

If you have further questions, about appointing someone to speak or make healthcare decisions on your behalf contact Health Choice Generations Member Services, 8 am - 8 pm, 7 days a week (except holidays), at 1-800-656-8991 (TTY users call 1-800-842-4681).

Appointment of Representative
Appointment of Representative - H5587_2006_92. CMS accepted 5/8/2006

back to top