Search results with tag "Authorized representative"
Appointment of Authorized Representative Part A: Tell us ...
www.dhcs.ca.govAppointment 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
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.
In-Home Services License Application Packet
www.doh.wa.govSignature of legal owner or authorized representative. Date signed. Print name of legal owner or authorized representative. Print title of legal owner or authorized representative. Additional Information: For more information on serving state funded DSHS clients, please contact your local
Appointing an Authorized Representative - SC DHHS
www1.scdhhs.govAppointment of Authorized Representative for Medicaid Applications/Reviews and Appeals Name of Medicaid applicant/member Social Security Number Appointing an Authorized Representative Mail your signed form to: SCDHHS - Central Mail, PO Box 100101, Columbia, SC 29202-3101 Fax: (888) 820-1204
MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA …
www.clearstream.comCompetent Authority or his authorized representative or authorized tax office in the country where the income recipient is a tax resident before submited to Indonesian withholding agent/custodian. Contact Number, / / (9) DGT-1 Page 1 Part I Part III Capacity/designation of (18) DECLARATION BY THE INCOME RECIPIENT (BANKING INSTITUTION AND ...
LDSS-4942 NYSOTDA SUPPLEMENTAL NUTRITION …
otda.ny.govAllowing someone else to use your electronic benefit transfer (EBT) card in exchange for cash, firearms, ammunition, explosives, or drugs or to purchase food for individuals who are not members of the SNAP household. Note: Both the applicant and/or authorized representative are subject to the above penalties.
AJ Employment Services WEEKLY TIME SHEETS …
ajemployment.netI hereby certify that the hours shown hereon were worked by me during the week ending designated and were certified by an authorized representative of the customer.
OREGON RETIREMENT SAVINGS PROGRAM 170 …
www.oregon.govEmployer Exemptions (1) An authorized representative of an Employer may file a Certificate of Exemption with the Program by certifying, through the Program Administrator’s internet portal or other means of
PD 542-061 Verification of Crime-Lost Property
www.nyc.govVERIFICATION OF CRIME/LOST PROPERTY PD 542-061 (Rev. 0 -16) Requests from complainants/victims or their authorized representative will be completed free of …
Authorized Representative Standard Agreement for ...
www.dhcs.ca.govBy 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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