Skip to Main Content

Authorized 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 organizational determination through an appointed representative, you should download the CMS-1696 Appointment of Representative Form (PDF), complete it and mail it to:

Part C (and Part B Drugs) Appeals, and
Part C and D Grievances:

Buckeye Health Plan - MyCare Ohio
Appeals and Grievances
Medicare Operations
7700 Forsyth Blvd.
St. Louis, MO 63105
Fax: 1-844-273-2671

Part D Appeals:

Buckeye Health Plan - MyCare Ohio
Medicare Part D Appeals
PO Box 31383
Tampa, FL 33631-3383
Fax: 1-866-388-1766

If you have questions, please call Member Services at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, 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.,,,,,,