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Designation Form. You can submit this form if you would like to designate an authorized representative to act on your behalf.
An authorised representative may be someone with parental responsibility, a carer, family member, legal guardian or someone with enduring power of attorney.
What is an Authorization Form? An authorization form is a document that is duly endorsed by an individual or organisation which grants permission to another individual or organisation to proceed with certain actions. It is often used to grant permission to carry out a specific action for a fixed period of time.
A designated representative is someone whom you appoint and authorize to act on your behalf and represent your administrative interests in the WTC Health Program.
By signing the authorization, an individual is giving consent to have their health information used or disclosed for the reasons stated on the authorization.

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An authorized representative is the person you choose to help with or handle affairs related to your health care services. This can be a Power of Attorney, a family member, friend, caregiver or an advocate. Your authorized representative would help you with an exception, appeal, or grievance.
Designated authorized representative. A designated representative is someone whom you appoint and authorize to act on your behalf and represent you to complete the administrative requirements necessary for receiving Paid Family and Medical Leave benefits.

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