Appointment Of Authorized Representative

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Appointment of Authorized Representative Part A: Tell us ...

www.dhcs.ca.gov

Appointment of Authorized Representative 1 . M. C 382 (6/18) Use this form to appoint an individual or organization as your Medi-Cal authorized representative. Your authorized representative may act for you on all duties related to your Medi-Cal eligibility and enrollment. Or, you may also limit duties. You may cancel or change this appointment at

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Appointment of Authorized Representative Form - …

www.maine.gov

Appointment of an Authorized Representative You have the right to appoint an authorized representative to act on your behalf with the Department. If you want to name a person or organization as your authorized representative, use this form. We are committed to the privacy of your health information. Please read this form carefully.

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Authorized Representative Standard Agreement for ...

www.dhcs.ca.gov

By si gning below, I hereby accept appointment as an auth orized representative for the organization named above. I understand and agree that: • I am acting as an authorized representative for the above-named organization that the applicant or beneficiary appointed as an authorized representative. I am not acting in my individual capacity.

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Appointment of Taxpayer Representative, Form M-5008-R

www.state.nj.us

The representative(s) is/are authorized to receive and inspect confidential tax records and is/are granted full power to act with re-spect to the tax matters described in Section 3 above, and to do and perform all such acts as I/we could do or perform. The authority granted by this appointment does not include the power to endorse a refund check.

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Appointment of Representative - CMS

www.cms.gov

Appointment of Representative Name of Party Medicare Number (beneficiary as party) or National Provider Identifier (provider or supplier as party) Section 1: Appointment of Representative To be completed by the party seeking representation (i.e., the Medicare beneficiary, the provider or the supplier):

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