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Non-Medicare designation of authorized party — completed forms
No phone listed for this route
Fax866-250-5178
Published hoursNot published in this record
Confirm the exact product or service
National contact — confirm product and location
Completed non-Medicare Designation of Authorized Party forms; the form separately instructs Medicare participants to use CMS-1696 and mail it to Customer Care at this address.
The current linked form says it is for non-Medicare participants. Do not use it to imply that someone is already authorized. Its fax/mail are form intake, not claim or PA intake. Written revocation is addressed to the Privacy Officer separately.
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