Medicare Appointment of Representative Form

You can give someone permission to help with your care.

An 'Appointment of Representative' can allow someone to talk to us about your health or coverage or make requests for you. You can download the form below or call us if you need us to send you the form.

After you have filled out the form, your appointed reprentative must sign it and send it to us, by mail or fax. This person will then be your appointed representative for one year from the date you both sign the Appointment of Representative form.

MAIL
Denver Health Medical Plan, Inc.
Attn: Health Plan Services
777 Bannock St. MC6000
Denver, CO 80204

FAX
303-602-2138

If you have questions or need help, call Health Plan Services at 303-602-2111, or toll free 1-877-956-2111, TTY 711.