How to Appoint a Representative

You can ask us for a coverage determination or an appeal for yourself, or your prescribing physician or someone you name may do it for you. You may also choose another person to file a grievance on your behalf. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date an Appointment of Representative Form: English | Español or sign and date a statement that gives the person legal permission to act as your appointed representative. This statement must be sent to us at:

Elderplan, Inc.
Grievances and Appeals Department
6323 Seventh Avenue
Brooklyn, NY 11220

You can call us at 1-800-353-3765, 8 a.m. – 8 p.m., 7 days a week (for TTY, call 711), to learn how to name your appointed representative.

You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.

If you would like to request an aggregate number of grievances, appeals and exceptions filed, please contact our Member Services Department at 1-800-353-3765 (for TTY, call 711), 8 a.m. – 8 p.m., 7 days a week.

Questions? Call Elderplan today.

1-800-353-3765

[TTY 711]

for the hearing impaired

Hours of Operation:
8 a.m. - 8 p.m., 7 days a week

Elderplan is available
in the 5 boroughs of NYC,
Nassau, Suffolk, Westchester
and Monroe counties.

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