Medical Appeals & Grievances Forms
You have the right to appoint a person to file a grievance, coverage determination, exception or appeal for you. You will need to fill out an Appointment of Representation form and have that form signed by the individual you would like to represent you as well as yourself. Once you have completed the form, you must submit that form to GEMCare Health Plan before we can talk to your representative.
Appointment of Representative Form - (PDF)
Use this form to appoint a person as your representative who acts on your behalf.
To access this form on the CMS website, click here.
Medical Appeal & Grievance Form (PDF)
Use this form to submit an appeal or grievance request to GEMCare Health Plan for medical services.