Information for Caregivers and Family
Becoming a Designated Representative
An appointed representative can be a friend, relative, advocate, doctor or anyone else of the beneficiary’s choosing. In order to act as an appointed representative for someone enrolled in a Community CCRxsm plan, you and the person enrolled in the plan must sign and date an Appointment of Representative Form.
Mail completed forms to:
Community CCRx
Appointment of Representative Form
Medicare Prescription Drug Program
P.O. Box 5205
Rensselaer, NY 12144-5205
You can also call us at 1-866-684-5353 (TTY/TTD users call 1-866-684-5351) 8 a.m. to 8 p.m., every day, to learn more about naming a representative.