TotalCare (HMO D-SNP) Appointment of Representative

Fill out this form to appoint a representative. You can choose a personal representative to act on your behalf for your claim, appeal, grievance, or request. This person will have access to all of your personal health information. If you have questions, contact TotalCare Member Services at 833-530-9015 (TTY: 800-735-2929 (Dial 711)).

Please send the completed form to:

Member Services
1600 Green Hills Rd., Suite 101
Scotts Valley, CA 95066-4981

Or email: [email protected]
Or fax: 831-430-5856

Read the instructions on how to download and fill out a form.

All fields in Sections 1 and 2 are required unless marked optional. Sections 3 and 4 must be completed by the representative if applicable.