Authorized Representative Form 2021-05-21-2025

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Legally authorized representative means the person legally authorized to act on behalf of the individual with a disability with respect to providing consent to medical treatment or procedures not prohibited by law which may be suggested, recommended, prescribed or directed by a duly licensed physician or as otherwise
An Authorized Representative can be family members, friends, or any other individual you choose. For example, you may want your spouse or adult child to help with billing questions, booking appointments, or to be aware of your health status.
How Do I Apply for Medicaid? *If you need help reading this information or communicating with us, ask us or call 1-877-423-4746.
An Authorized Representative is an individual with legal authority to bind the government entity (e.g., the Chief Executive Officer of the government entity). An Authorized Representative must sign the Acceptance of Award terms for it to be valid.
Authorized Representatives An Authorized Representative is someone who is legally allowed to help a Medicaid or PeachCare for Kids member during the renewal process. Providers, hospitals, family members, and friends who need to help a member must become an Authorized Representative.
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If the represented person is bound, the signature of the representative is the authorized signature of the represented person and the represented person is liable on the instrument, whether or not identified in the instrument.
Who can be an authorized representative? An authorized representative can be a friend, family member, or someone else you trust. Note: Appointing a certified Navigator or Certified Application Counselor (CAC) as your authorized representative prohibits them from operating in their official capacity as an assister.

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