Authorization To Sign Vendor Agreements And Payment Request Forms When There Is No Employer Of Record Template printable pdf download

AUTHORIZATION TO SIGN VENDOR AGREEMENTS AND PAYMENT REQUEST FORMS WHEN

THERE IS NO EMPLOYER OF RECORD

Mi Via PARTICIPANTS ONLY

The Mi Via Program allows a participant or his/her authorized representative to sign Vendor Agreements and Payment

Request Forms (PRF) for vendor payments without having to go through the Employer of Record (EOR) enrollment

process under the following circumstances:

1) All Mi Via service providers must be vendors. If employees are currently providing services, they will need to be

terminated before this form can take effect.

2) If the participant is to be the one authorized to sign the Vendor Agreements and PRF’s, the participant must be

at least 18 years of age, and cannot have an authorized representative over financial matters ( for example a

court-appointed legal guardian, a conservator over financial matters, or a person acting under the authority of a

valid power of attorney) ; or

3) If an authorized representative is to be the one authorized to sign Vendor Agreements and PRF’s, a “Self-

Direction Appointment of Authorized Representative” form must be completed, and the authorized

representative cannot be a paid provider of Mi Via Services for the participant.

Please complete A if the participant is applying to be authorized to sign Vendor Agreements and PRF’s.

A. Print Participant Name_____________________________________ Medicaid ID #_______________________

Address and Phone Number____________________________________________________________________

___________________________________________________________________________________________

By signing this form, I attest that I do not have an authorized representative over financial matters. I also

understand that all of my providers must be vendors. I understand that if I currently have employees providing

Mi Via services to me, they must be terminated.

Participant Signature_________________________________________________

Date__________________

Please complete B if the participant’s Authorized Representative is applying to be authorized to sign Vendor Agreements

and PRF’s and submit the Self-Direction Appointment of Authorized Representative form with this form.

B. Print Participant Name_____________________________________ Medicaid ID#________________________

Print Authorized Representative Name____________________________________________________________

Authorized Representative Address and Phone Number______________________________________________

___________________________________________________________________________________________

By signing this form, I attest that I am not a paid provider of Mi Via services for the participant. I also

understand that all of the participant’s providers must be vendors. I understand that if there currently are

employees providing Mi Via services to the participant, they must be terminated.

Authorized Representative Signature______________________________________

Date_________________

Authorization to Sign PRF’s if no EOR 06/01/16

Authorization To Sign Vendor Agreements And Payment Request Forms When There Is No Employer Of Record Template