Manage Your Plan

Appoint a Representative

If you need to request a coverage determination, you can make the request yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your appointed representative. Your representative can be a friend, relative, advocate, doctor or anyone else you choose. In order to allow someone else to act for you, you and the person who will act as your representative must sign and date an Appointment of Representative Form.

Mail completed forms to:
Community CCRx
Appointment of Representative Form
Medicare Prescription Drug Program
P.O. Box 5205
Rensselaer, NY 12144-5205

You can also call us at 1-866-684-5353 (TTY/TDD users call 1-866-684-5351) from 8 a.m. to 8 p.m., every day, to learn more about naming a representative.