Use the attached form to appoint a representative to act on your behalf for your claim, appeal, grievance or request. By signing this form and appointing this representative, you agree that the representative will be the main contact and have authority to make requests, present evidence, get information, and receive all communication about your action. This person may see your personal medical information.

www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012207

Once you complete the form, please submit it to Serenity Care PACE:

For Springfield Participants

Mail / In-person:
604 Cottage Street
Springfield, MA 01104
Fax: (413) 747-3979

For Newton Participants

Mail / In-person:
149 California Street
Newton, MA 02458
Fax: (617) 916-0946