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 form CMS-1696 (Please note: By clicking on this link, you will be leaving the Buckeye website), complete it, and mail it to:

Buckeye Health Plan
Attn: Appeals and Grievances
4349 Easton Way
Suite 300
Columbus, Ohio 43219

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.