Medicaid And Kid Care Chip Renewal Form Page 11
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12Attachment C
Assistance with completing this application
You can choose an authorized representative
An authorized representative is a trusted friend, partner, or lawyer you choose to sign
your renewal form, get information about this renewal form, and act for you with this agency.
Do you want an authorized representative?
Yes
No
If yes, you want an authorized representative, answer the questions below.
We show that you chose this person as your authorized representative:
Do you still want this person to be your authorized representative?
Yes
No
Not applicable
If yes, has any of his or her information changed?
Yes
No
If your authorized representative's information has changed, or if you would like a different authorized representative,
please write the new information here:
Name of authorized representative:
Address:
Apartment #
City
State
ZIP code
Phone number:
Home
Cell
Work
Other
Number:
By signing, you allow this person to sign your renewal form, to get information about this renewal form, and to act for you with this agency.
Your signature:
Date:
?
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Questions?
Call our customer service center at 1-855-294-2127 (TTY/TDD: 1-855-329-5204).
The call is free. You can call 7:00 a.m. to 6:00 p.m. Monday to Friday. Or visit
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