Sample Designation Of Authorized Representative Form printable pdf download

Sample Designation Of Authorized Representative Form

Sample Designation of Authorized Representative Form

Designation of Authorized Representative

RI PersonalChoice Program

Consumer Name_________________________________________________

Address ________________________________________________________

City _____________________________________ State _____ Zip ________

Telephone # ________________ Medical Assistance # _____-_____-______

I Hereby Designate:

Name: __________________________________________________________

Address: ________________________________________________________

City: _______________________________ State: ________ ZIP: _________

to serve as my representative in the RI PersonalChoice Program. My representative will

complete and sign all forms and agree to meet all documentation requirements for this Program.

My representative will assist me in using the RI PersonalChoice monthly allowance to purchase

the services and items that meet my personal care needs as documented in my approved

Individual Service and Spending Plan. My representative will assure that my independence and

choices are honored and supported.

___________________________________________

________________

Consumer’s Signature

Date

I hereby agree to serve as the Representative for the above named Consumer and understand my

responsibilities and duties under the RI PersonalChoice program.

___________________________________________

________________

Authorized Representatives Signature

Date

___________________________________________

_________________

Witness Signature

Date

(Required if either the Consumer or Representative sign with a mark)

Resource Guide: Managing Change

Sample Designation Of Authorized Representative Form