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Farm Bureau Health Plans

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Farm Bureau Select Rx 2020 Farm Bureau Essential Rx 2020 Farm Bureau Select Rx 2021 Farm Bureau Essential Rx 2021 How Medicare Works Formulary Senior Savings Model Medication Therapy Management (MTM) How to Appoint a Representative Quality Assurance Programs Documents & Forms
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Medicare.gov Resources

Medicare.gov Medicare Complaint Form Medicare Prescription Drug Coverage Determinations Best Available Evidence for Low-Income Subsidy

How to Appoint a Representative

You can designate someone to act on your behalf.  This person is called your “authorized representative”.  Your authorized representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during certain situations, such as filing a grievance, an appeal, or requesting an exception.

To appoint an authorized representative, complete the Appointment of Representative form.  Both you and the person you have named as an authorized representative must sign the form.  Please mail the completed form to:  OptumRx, Attn: Commitment and Follow Up Team, 6860 West 115th Street, Mail Stop: KS015-1000, Overland Park, KS 66211-2457 or fax to 1-866-889-2116. Please keep a copy of this form for your records.  


Download an Appointment of Representative Form

If you don’t want to use the form, you may also submit a written request. Be sure to include:

  • Your name, address, phone number, and Medicare number
  • A statement appointing someone as your representative
  • The name, address, and phone number of your representative
  • The professional status of your representative (like a doctor) or their relationship to you
  • A statement authorizing the release of your personal and identifiable health information to your representative
  • A statement explaining why you’re being represented and to what extent
  • Your signature and the date you signed the request
  • Your representative's signature and the date they signed the request