Appointment Of An Authorized Representative Form
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2Appointment of an Authorized Representative
You have the right to appoint an authorized representative to act on your behalf with the Department.
If you want to name a person or organization as your authorized representative, use this form.
We are committed to the privacy of your health information. Please read this form carefully.
Individual’s Name:
Individual’s Date of Birth:
Individual’s Social Security Number:
Individual’s Address:
I (individual named above) hereby appoint the following individual/organization to act as Authorized
Representative for me.
Toole and Powers, P.A.
Authorized Representative’s Name:
75 Market Street, Suite 301, Portland, ME 04101
Address:
(207) 879-6054
Telephone number:
Email address:
Existing legal authority (if any) for individual/organization to act on my behalf (check all that apply and
attach copy of documentation):
_____Guardianship
_____Power of Attorney
_____Advance Healthcare Directive
_____Other:____________________
By making this appointment, I want my Authorized Representative to (check all that apply):
Sign and submit an application on my behalf (including an electronic application)
Sign and submit a recertification form on my behalf (including an electronic recertification)
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