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An Authorized Representative (AR) must be knowledgeable of the individual’s circumstances. AR responsibilities include, but are not limited to: knowledge of income and resources and household composition and tax relationships.
Use this form to appoint an individual or organization as your Medi-Cal authorized representative. Your authorized representative may act for you on all duties related to your Medi-Cal eligibility and enrollment. Or, you may also limit duties. You may cancel or change this appointment at any time.
DFR: Becoming an authorized representative. All Counties. Fax: 888-436-9199 or deliver or mail to your local county office. If you do not see the form you are searching for in the sections below, you can search the state forms library.
The representative should complete the form OMHA-118, “Petition to Obtain Approval of a Fee for Representing a Beneficiary” and file it with the request for ALJ hearing, OMHA review, or request for Medicare Appeals Council review.
If you want someone to act on your behalf in applying for benefits or act for you on an ongoing basis in regards to your case, you must complete an Authorized Representative for Health Coverage Form. You can get this form directly from DFR or via the link below.
Form 2848 is used to authorize an eligible individual to represent another person before the IRS. Information about Form 2848, Power of Attorney and Declaration of Representative, including recent updates, related forms, and instructions on how to file.
Form SSA-1696 | Claimant’s Appointment of a Representative. If you have a case before us and need assistance, you can appoint a representative to help you. Your representative can be an attorney or a non-attorney, but must be qualified and comply with our published rules of conduct.
To fill out an Appoint an Authorized Representative for My Appeal Form online, you’ll need to download it onto your computer first. Step 1: Download the Appoint an Authorized Representative for My Appeal Form. Right click on this Appoint an Authorized Representative for My Appeal Form (PDF, 585 KB). Step 2: Save the form on your computer.
A fiduciary may authorize an individual to represent or perform certain acts on behalf of the person or entity by filing a power of attorney that names the eligible individual (s) as representative (s) for the person or entity.
Authorized Representative Designation Form. You can submit this form if you would like to designate an authorized representative to act on your behalf. If an authorized representative signed your application for you, or if you are an authorized representative applying on behalf of someone else, you MUST submit this form for the application to ...