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Filling out the Appoint an Authorized Representative for My Appeal Form electronically

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 MarketplaceÂź at the location shown on the form.
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