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Appointment of Authorized Representative Form - …
www.maine.govAppointment 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.
Appointment of Authorized Representative Part A: Tell us ...
www.dhcs.ca.govPart B: Tell us about the authorized representative: Mailing a. ddress (number, street, city, state, ZIP code): E-mail address: Part C: Authorized representative duties: E. xamples of authorized representative duties • Complete and sign the application • Complete and sign redetermination forms • Give us information we ask for • Report ...