If you want a friend, relative, your doctor or other provider, or other person to be your representative, print out and complete this form. The form must be signed by you and by the person who you would like to act on your behalf. You may submit your Appointment of Representative form by mail or fax.
MetroPlus Health Plan
Attention: Appeals Coordinator
50 Water Street, 7th Floor, 33 Maiden Lane
New York, NY 10004