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Representatives

There are two kinds of Representatives, the differences are explained below.

Appointment of Representative

Can be someone such as a relative, friend, advocate, doctor, or anyone else you want to act on your behalf to file a grievance, coverage determination, or appeal. This appointment can be completed by using the Appointment of Representative Form or an equivalent notice. For more information, please contact us.

A Representative to Release PHI

Can be someone such as a relative, friend, advocate, or anyone else you want us to disclose your personal, protected health information (PHI) to. You can give this access by completing the PHI Release Form. For more information, please contact us.

Note: Representative to Release PHI may not file a grievance, coverage determination, or appeal on your behalf.

Other persons may already be authorized under State law to act for you. Please contact us for more information.

Both forms may be completed and sent via the following methods:

Mail

Granite Alliance Insurance Company
PO Box 1382
Maryland Heights, MO 63043

Fax

888-656-8099

S3875_WEBEGWP

Website content was last updated on 1/20/2021.

Granite Alliance Insurance Company is a Medicare-approved Prescription Drug Plan. Enrollment in Granite Alliance depends on contract renewal.

View our Non-Discrimination Notice.