Appointment of Representative Form
If you need someone to file a grievance, coverage determination or appeal on your behalf, you can name a relative, friend, advocate, doctor or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.
To download a copy of Medicare's Appointment of Representative form, click here.
If you want to appoint a representative, you should complete the Appointment of Representative form on the Medicare.gov website and mail it to:
KelseyCare AdvantageATTN: Member ServicesP.O. Box 841569Pearland, Tx 77584
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Coordination of Benefits FormAfter you enroll, if you have more than one medical plan, you can complete the Coordination of Benefits form. Having more than one medical plan may save on medical costs by coordinating your benefits. The information you provide will help us determine if your other medical plan is primary or secondary to your KelseyCare Advantage plan. Go to the Coordination of Benefits Form.
Order New or Replacement ID CardYour ID card shows information important to your health insurance coverage. You don’t need a new ID card every year. If you change plans, we will send you a new ID card.
For a new or replacement ID card, you may request one here or contact a KelseyCare Advantage Member Services representative at one of the phone numbers below and a new ID card will be sent to the address on file for you.
(713)-442-CARE (2273) or toll free: (877)-853-9075(TTY/TDD 1-866-302-9336)8 a.m. to 5 p.m., Monday through Friday
Press 2 if you are a current member of KelseyCare Advantage
Press 1 if you have a question regarding your medical benefits
Ask an ExpertFor more information about your KelseyCare Advantage benefits, contact us at: