Appointment of Representative
You can appoint a person to act on your behalf if any of the following situations apply to you. Click on the links below to learn more.
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You can appoint a person to act on your behalf if any of the following situations apply to you. Click on the links below to learn more.
You can ask our plan to provide a medical coverage decision if you are in any of the following situations:
Please refer to your Evidence of Coverage for complete details. You can access your Evidence of Coverage in the UPMC Health Plan member site, your secure member website, or through the UPMC Health Plan app:
Log in to the UPMC Health Plan member site
Download the UPMC Health Plan app
If you would like to appoint a person to act on your behalf, print the form and complete the required fields. Fax or mail the completed form to us, or upload it through the UPMC Health Plan member site. Log in, select Documents and Forms, then click: Forms and Guides, Personal Information and Privacy, Appointment of Representative Form.
We must receive this form, an equivalent written notice, or a photocopy of an original form to process your request. Once received, this form will be valid for one year from the date you and your representative sign it. A new form will not be needed for each request until after a year unless you wish to designate another representative.
Fax: 412-230-4213
Mail: UPMC for Life
Clinical Operations, 37th Floor
600 Grant Street
Pittsburgh, PA 15219
Appointment of Representative Form
Nombramiento de Representante
Language Assistance
You can request a medical claim reimbursement if you are a UPMC for Life member and have paid out-of-pocket for covered medical services. If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. You can also upload it through the UPMC Health Plan member site. Log in, select Documents and Forms, then click: Forms and Guides, Personal Information and Privacy, Appointment of Representative Form.
We must receive this form, an equivalent written notice, or a photocopy of an original form to process your request. Once received, this form will be valid for one year from the date you and your representative sign it. A new form will not be needed for each request until after a year unless you wish to designate another representative. If you have any questions, please call our Member Services Department at 1-877-539-3080 (TTY: 711).
Fax: 412-454-8519
Mail: UPMC Health Plan/UPMC Health Benefits
Claims Department
PO Box 2999
Pittsburgh, PA 15230
Appointment of Representative Form
Nombramiento de Representante
Language Assistance
If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. You can also upload it through the UPMC Health Plan member site. Log in, select Documents and Forms, then click: Forms and Guides, Personal Information and Privacy, Appointment of Representative Form.
We must receive this form, an equivalent written notice, or a photocopy of an original form to process your request. Once received, this form will be valid for one year from the date you and your representative sign it. A new form will not be needed for each request until after a year unless you wish to designate another representative. If you have any questions, please call our Member Services Department at 1-877-539-3080 (TTY: 711).Appointment of Representative Form
Nombramiento de Representante
Language Assistance
UPMC for Life members can request a coverage determination/exception for a Part D prescription drug. View the types of coverage determination requests.
If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. You can also upload it through the UPMC Health Plan member site. Log in, select Documents and Forms, then click: Forms and Guides, Personal Information and Privacy, Appointment of Representative Form.
We must receive this form, an equivalent written notice, or a photocopy of an original form to process your request. Once received, this form will be valid for one year from the date you and your representative sign it. A new form will not be needed for each request until after a year unless you wish to designate another representative. If you have any questions, please call our Member Services Department at 1-877-539-3080 (TTY: 711).
Fax: 412-454-7722
Mail: UPMC Health Plan Pharmacy Department
U.S. Steel Tower, 12th Floor
600 Grant Street
Pittsburgh, PA 15219
Appointment of Representative Form
Nombramiento de Representante
Language Assistance
If UPMC for Life denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision.
If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. You can also upload it through the UPMC Health Plan member site. Log in, select Documents and Forms, then click: Forms and Guides, Personal Information and Privacy, Appointment of Representative Form.
We must receive this form, an equivalent written notice, or a photocopy of an original form to process your request. Once received, this form will be valid for one year from the date you and your representative sign it. A new form will not be needed for each request until after a year unless you wish to designate another representative. If you have any questions, please call our Member Services Department at 1-877-539-3080 (TTY: 711).Appointment of Representative Form
Nombramiento de Representante
Language Assistance
UPMC for Life members can apply for reimbursement for Part D prescription drugs. View your plan’s Evidence of Coverage to learn more about when to ask us for reimbursement. You can access your Evidence of Coverage online through the UPMC Health Plan app or by logging in to the UPMC Health Plan member site
If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. You can also upload it through the UPMC Health Plan member site. Log in, select Documents and Forms, then click: Forms and Guides, Personal Information and Privacy, Appointment of Representative Form.
Appointment of Representative Form
Nombramiento de Representante
Language Assistance
UPMC for Life works hard to improve the quality of care and service that you get as a member. Let us know right away if you have questions or problems with covered services or the care you receive. You can call our Member Services Department at 1-877-539-3080 (TTY: 711).
If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. You can also upload it through the UPMC Health Plan member site. Log in, select Documents and Forms, then click: Forms and Guides, Personal Information and Privacy, Appointment of Representative Form.
A UPMC for Life member who has been disenrolled for nonpayment of plan premiums can request to be reinstated by calling our Member Services Department at 1-877-539-3080 (TTY: 711).
If you would like to request reinstatement on behalf of the member, you and the member must complete the Appointment of Representative form below. Print the form below, complete the required fields, and fax or mail it to us. You can also upload it through the UPMC Health Plan member site. Log in, select Documents and Forms, then click: Forms and Guides, Personal Information and Privacy, Appointment of Representative Form.
We must receive this form, an equivalent written notice, or a photocopy of an original form to process your request. Once received, this form will be valid for one year from the date you and your representative sign it. A new form will not be needed for each request until after a year unless you wish to designate another representative. If you have any questions, please call our Member Services Department at 1-877-539-3080 (TTY: 711).
Fax: 412-454-7520
Mail: UPMC for Life
PO Box 2987
Pittsburgh, PA 15230-2987
Appointment of Representative Form
Nombramiento de Representante
Language Assistance
