Enrollee's Information






Complete the following section ONLY if the person making this request is not the enrollee or prescriber:

Requestor's Information


Representation documentation for appeal requests made by someone other than enrollee or the enrollee’s prescriber:

Attach documentation showing the authority too represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted at the coverage determination level. For more information on appointing a representative, contact your plan or 1-800-Medicare


Prescription drug you are requesting


If Yes:
  (attach copy of receipt)


Prescriber's Information



Important Note: Expedited Decisions

If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received. 

Please explain your reasons for appealing

Signature of person requesting the coverage determination (the enrollee, or the enrollee’s prescriber or representative):