Appoint a representative, file a grievance or appeal, request a coverage determination, and more.
Name an Appointed Representative
You or someone you name may file a complaint (grievance) or appeal for you. The person you name would be your “appointed representative.” You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act on your behalf.
To appoint a representative, fill out CMS Appointment of Representative Form (CMS Form-1696).
Print and mail the form to:
- Lagniappe Advantage
- Appeals and Grievances Department
- PO Box 1030
- Glen Burnie, MD 21060
You may also send a fax to 1-833-610-2382
For a description of, and information on how to appoint a representative, you may also call Member Services at 1-844-217-0052 (TTY 711).
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CMS ID Number: H6566_Website,Last modified: November 8, 2025