Appoint An Authorized Representative For My Appeal

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DEPARTMENT OF HEALTH & HUMAN SERVICES
MARKETPLACE APPEALS CENTER
P.O. BOX 311
PITTSTON, PA 18640
APPOINT AN AUTHORIZED REPRESENTATIVE FOR MY APPEAL
You have the right to choose an authorized representative to help you with an eligibility
appeal. This is a trusted person who has your permission to talk about your appeal with us, see
your information, and act for you on matters related to your appeal, including getting
information about you and signing your appeal request on your behalf. If you want to have an
authorized representative, complete and submit this form.
Your information
1. Name (First name, Middle name, Last name)
2.
Appeal Case ID # (if you have one)
3.
Date of birth (mm/dd/yyyy)
APL-
Your authorized representative’s information
4. Name (First name, Middle name, Last name)
5. Mailing address
6. Apartment or Suite number
7. City
8. State
9. ZIP code
10. Phone number with area code
11. Organization name (if applicable)
12. ID number (if applicable)
Your signature
By signing below, you allow the person named in box 4 to sign your appeal request, get official information
about your appeal, and/or act for you on all future matters related to this appeal.
13.
14. Date signed (mm/dd/yyyy)
Signature
Make a copy for your records and mail this completed form to:
Marketplace Appeals Center
P.O. Box 311
Pittston, PA 18640
You may also fax the form to our secure fax line at 1-877-369-0129.
To change or remove your authorized representative, or for more information, contact the
Marketplace Appeals Center at 1-855-231-1751. TTY users should call 1-855-739-2231. Our
1
OMB Control Number 0938-1213 (expires 11/30/16)
CMS I14-2 (03/30/2015)

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