Authorized Representative

Appointing a Representative

If you need someone to file a grievance, coverage determination, organization determination, or appeal on your behalf, you can name a relative, friend, advocate, doctor, or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

If you are requesting an organization determination or coverage determination through an appointed representative, you should download form CMS-1696 complete it, and mail it to:

Buckeye Health Plan – MyCare Ohio
Attn: Appeals and Grievances
4349 Easton Way
Suite 400
Columbus, Ohio 43219

If you have questions, call Buckeye Member Services at 1-866-549-8289. Hours are 8 a.m. to 8 p.m., Monday through Friday. On weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.


Last Updated: 09/30/2017