California Pre-Service Authorized Representative Form

The following form (or the form in the link below) should be used to appoint an individual or your practitioner as your Authorized Representative for California Pre-Service Clinical Appeals only. Your Authorized Representative may appeal on your behalf decisions in which not all of the clinical services requested by your practitioner were determined to be medically necessary. You may cancel or change this appointment of Authorized Representative at any time.

Please email, fax or mail the completed form to the American Specialty Health Appeals and Grievances Department.


Fax Number:

Box 509001 San Diego, CA. 92150