How to Appoint a Representative with CMS Form 1696
Send this form to the same location where you are sending (or have already sent) your appeal if you are filing an appeal, grievance, or complaint if you are filing a grievance or complaint, or an initial determination or decision if you are requesting an initial determination or decision.
If additional help is needed, contact Edenbridge PACE of West Baltimore at 1-443-961-0796 or Toll Free at 1-833-722-3225. TTY users please call 1-443-961-0801.