Appointment Of An Authorized Representative Form Page 2
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2Receive copies of Notices of Decision and all other written communications from the
Department; I’m aware I may also need to complete an Authorization to Release Information
form
Obtain Food Supplement benefits on behalf of my household
Represent me at a fair hearing; I’m aware that I may also need to complete an Authorization to
Release Information form
Request an appeal, withdraw an appeal and represent me in an appeal.
Other (please describe) _________________________________________________________
Act on my behalf in all other matters with the Department of Health and Human Services; I’m
aware I may also need to complete an Authorization to Release Information form
•
My authorized representative’s authority is limited to the task or tasks I have delegated, above.
•
This appointment is valid until:
I change this appointment in writing by notifying the Department that this Authorized
Representative is no longer authorized to act on my behalf; or
My Authorized Representative informs the Department in writing that he/she is no
longer acting as my Authorized Representative.
•
I understand that taking back this appointment does not apply to any documents signed by or
sent to my Authorized Representative before I took back the appointment.
•
I understand that if I want my Authorized Representative to receive copies of the Notices of
Decision and all other written communications from the Department, the information shared
will be for all programs in which I participate that are administered by the Department.
•
I understand that an appointment of a representative for the TANF or Food Supplement
programs is a representative for both me and my household and that my household will be
liable for any overissuance of Food Supplement or TANF benefits that results from erroneous
information given by the authorized representative.
I am signing this form voluntarily, and I have the right to a signed copy of this form if I request one.
Signature of the Individual:
Date:
For the Authorized Representative
I (Individual or Organization Named as Authorized Representative) hereby agree to:
•
Fulfill all above-designated responsibilities on behalf of the individual who appointed me as
his/her Authorized Representative;
•
Maintain the confidentiality of any information regarding the individual who appointed me as
his/her Authorized Representative;
•
Adhere to the regulations 42 C.F.R. § 431(F) and at 45 CFR § 155.260(f) (relating to
confidentiality of information), 42 C.F.R. § 447.10 (relating to the prohibition against
reassignment of provider claims as appropriate for a facility or an organization acting on the
facility’s behalf), as well as all other applicable state and federal laws concerning conflicts of
interest and confidentiality of information.
Signature of the Authorized Representative:
Date:
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