You can file a grievance or an appeal yourself. You can also choose someone to do this for you. This person is called your appointed representative.

Your appointed representative can be:

• A family member
• A friend
• A lawyer or advocate
• Your doctor or another health care provider
• Anyone you trust to act for you

To name an appointed representative, complete the CMS Appointment of Representative Form (CMS Form-1696) .

Send the completed form to:

Lagniappe Advantage
Appeals and Grievances Department
PO Box 1030
Glen Burnie, MD 21060

Fax to 1-833-610-2380

If you need help or have questions, call Member Services at 1-844-217-0052 (TTY 711).