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To act as my representative in connection with my claim(s) or asserted right(s) under: 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your Social Security Number and your name as the claimant. If applicable, include the wage earner's name.
- In Part I, appoint your representative by filling in their name and address. Specify the claims or rights under which they will represent you, such as Title II or Title XVI.
- Authorize the release of information by checking the appropriate boxes that allow your representative to access necessary details regarding your claim.
- Complete the signature section for both you (the claimant) and your appointed representative, ensuring all contact information is accurate.
- If applicable, fill out Part III regarding fee arrangements, selecting whether fees will be charged or waived.
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Related links
The claim may be filled by a duly authorized agent or other legal representative, provided evidence satisfactory to the Government is submitted with the claim
You have the right to appoint a qualified representative of your choice to represent you on any claim or asserted right under any of our programs.
Practitioners Right to be Informed of Application Status . To verify the status of your claims, please use Molinas Provider Portal. For other claims.