The BCBSIL Authorized Representative Designation form is a one-page PDF that lets a family member, friend, attorney, or doctor file and manage a Blue Cross Community Health Plans (BCCHP) appeal or grievance on your behalf. Until Blue Cross and Blue Shield of Illinois has a signed copy on file, it will not discuss the case with anyone other than you.1Blue Cross and Blue Shield of Illinois. Grievances, Appeals and Coverage Decisions – Section: How to Appoint a Representative
Where to Get the Form
Download the PDF from the BCCHP Forms and Documents page at bcbsil.com.2Blue Cross and Blue Shield of Illinois. BCCHP IL Medicaid Forms and Documents If you would rather have a paper copy mailed to you, call BCBSIL customer service at 1-800-538-8833.3Blue Cross and Blue Shield of Illinois. Contact BCBSIL Print clearly. Smudged or illegible fields slow the process down.
How to Complete the Form
The form is short, but every field matters. A blank line or a wrong ID number is the fastest way to get it kicked back.
Representative’s Information
Print the full name of the person you are authorizing. This can be a relative, friend, lawyer, or doctor.1Blue Cross and Blue Shield of Illinois. Grievances, Appeals and Coverage Decisions – Section: How to Appoint a Representative Fill in the representative’s complete mailing address, including apartment number if any, and enter both a daytime and an evening phone number.4Blue Cross and Blue Shield of Illinois. Blue Cross Community Health Plans Authorized Representative Designation
Description of the Appeal
Use the free-text field to briefly describe the service and the date or dates involved. Something like “denied physical therapy sessions, dates of service 3/10/2026 through 4/15/2026” works well. Be specific enough that BCBSIL can match the description to the right claim, because this description, not any checkbox, defines what your representative is authorized to handle.4Blue Cross and Blue Shield of Illinois. Blue Cross Community Health Plans Authorized Representative Designation
Your Information and Signature
Print your name exactly as it appears on your BCCHP benefit card and enter your Recipient ID Number (RIN). The RIN is on your BCCHP card. It is not your Social Security number. A mistyped RIN means BCBSIL cannot link the form to your account, so check it twice.4Blue Cross and Blue Shield of Illinois. Blue Cross Community Health Plans Authorized Representative Designation
Sign and date the bottom. If a parent, guardian, conservator, or other legal representative is signing for the member, that person must indicate the relationship using the options on the form. Notarization is not required.4Blue Cross and Blue Shield of Illinois. Blue Cross Community Health Plans Authorized Representative Designation
Where to Submit It
For most appeals, mail or fax the completed form to the BCCHP Appeals and Grievances unit:
Blue Cross and Blue Shield of Illinois
Blue Cross Community Health Plans
Attn: Appeals and Grievances
P.O. Box 660717
Dallas, TX 75266-0717
Fax: 1-866-643-7069.4Blue Cross and Blue Shield of Illinois. Blue Cross Community Health Plans Authorized Representative Designation
If your appeal involves a pharmacy service, send the form to Prime Therapeutics Appeals Department, 2900 Ames Crossing Road, Eagan, MN 55121, or fax it to 1-855-212-8110.5Blue Cross and Blue Shield of Illinois. Appeals and Grievances
BCBSIL generally needs the signed form in hand before it will process an appeal filed by anyone other than the member, so submit it early.1Blue Cross and Blue Shield of Illinois. Grievances, Appeals and Coverage Decisions – Section: How to Appoint a Representative Keep a copy of the signed form. If you fax it, save the confirmation page as proof of delivery.
Changing or Revoking the Designation
You can revoke the authorization at any time.4Blue Cross and Blue Shield of Illinois. Blue Cross Community Health Plans Authorized Representative Designation The form states this right but does not spell out a procedure. The safest approach is a signed letter stating you are revoking the authorization, along with your name and RIN, sent to the same Appeals and Grievances address or fax number. To switch representatives, submit a new designation form naming the replacement.
How Long the Authorization Lasts
The form does not list a blanket expiration date for adult members. Because it is tied to the specific appeal and description you wrote in, the authorization effectively lasts for the duration of that matter. For minors, a related BCBSIL authorization expires automatically when the child turns 18 unless proof of legal guardianship is on file.6Blue Cross and Blue Shield of Illinois. Standard Authorization Form If your appeal runs long or you expect to need representation for more than one issue, call customer service to confirm whether a single form still covers you.
If You Are a Parent of an Adult Dependent
The Authorized Representative Designation form is for appeals and grievances. It is not the right form for general access to an adult child’s health information. Once a dependent on your plan turns 18, federal privacy rules stop BCBSIL from discussing that person’s records with you unless the adult child authorizes it, and BCBSIL uses a separate Member Authorization Form for that purpose.7Blue Cross and Blue Shield of Illinois. Blue Cross Community Health Plans Member Authorization Form If a dependent is approaching 18, filing that paperwork before the birthday prevents a gap in your ability to help.