Application For Retroactive Medicaid Coverage - Department Of Human Services - Case Records Management Unit Form Page 4

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Attachment A
Authorized Representative
You can choose an authorized representative.
You can give a trusted person permission to talk about this retroactive Medicaid application form with us, see your information,
and act for you on matters related to this retroactive Medicaid application form, including getting information about your
retroactive Medicaid application form and signing your retroactive Medicaid application form on your behalf.
This person is called an "authorized representative". If you are a legally appointed representative for someone on this retroactive
Medicaid application form, submit proof with this application form. If you ever need to change your authorized representative,
contact Department of Human Services (DHS).
Name of authorized representative:
Address:
Apartment #
City
State
ZIP code
Phone number:
Home
Cell
Work
Other Number:
Number:
The Medicaid member requesting retroactive coverage needs to sign below to confirm selection of an authorized representative.
If the Medicaid member is unable to sign, then the authorized representative will have to provide proof of their appointment to
represent the Medicaid member. By signing, you allow this person to sign and submit your retroactive Medicaid application
form, get official information about this retroactive Medicaid form, receive copies of notices and other communications from
DHS and DC Health Link, and act on your behalf on all future matters with DHS and DC Health Link.
Your Signature:
Date
Printed Name:
4
D.C. Application for Retroactive Medicaid Coverage (3/2014)

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