Dhhs Form 3401 - Application For Nursing Home, Residential Or In-Home Care Page 10
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10Authorization for Release of Information and
Appointment of Authorized Representative
for Medicaid Applications/Reviews and Appeals
Name of Medicaid applicant/member
Social Security Number
Appointing an Authorized Representative
Would you like to allow someone to represent you on all matters related to your case?
You can give a trusted person or an organization permission to talk about your application with us, see your information, and act
for you on matters related to your application, including getting information about your application and signing your application
on your behalf. This person can also act for you on other matters, including reviews, appeals and managed care processes.
This person is called an “authorized representative.” The Medicaid eligibility worker can release any information regarding your
application/review and status to your authorized representative or any member of the organization indicated on this form. More
than one person or organization can serve as your authorized representative.
You can appoint, withdraw or change an authorized representative at any time. If you ever need to change your authorized
representative, contact Healthy Connections. If you are a legally appointed representative for someone on this application, you
do not need to complete this section.
New
Change
Addition
Name of Authorized Representative (First name, Middle name, Last name)
Remove this person or organization
as my authorized representative
Authorized Representative’s address (Leave blank if you don’t have one.)
Apartment or suite number
City
State
ZIP code
Authorized Representative’s phone number
Other phone number
Authorized Representative’s email address
Organization name (if applicable)
Unit* (if applicable)
ID number (if applicable)
*It is best to identify a specific unit for large organizations.
OR
Permission to Release Information
Is there anyone that you would like us to share information with about your application?
By completing this section, you can give permission for the following person to receive information about your application/
case, but they won’t have the ability to act on your behalf like an authorized representative. You also give SCDHHS permission to
release information about this application to this additional person or organization.
Name of person/organization
Phone
Address
City
State
ZIP
Unit (if applicable)
ID Number (if applicable)
Medicaid applicant/member’s signature
Date (mm/dd/yyyy)
If signing with an “X,” please have two people sign below as witnesses.
Witness:
Witness:
Member is incapacitated and unable to sign. SCDHHS reserves the right to verify member’s inability to sign. Provide reason:
Mail your signed form to: SCDHHS - Central Mail, PO Box 100101, Columbia, SC 29202-3101 Fax: (888) 820-1204
NEED HELP WITH YOUR APPLICATION?
Visit
SCDHHS.gov
or call us at 1-888-549-0820. Para obtener una copia de este
formulario en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-753-8583.
DHHS Form 1282 - Authorized Representative (October 2015)
Member Verification
Page 1 of 1
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