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F 10126a 2026
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- Click ‘Get Form’ to open f 10126a in the editor.
- Begin by indicating whether you completed the Medicaid, BadgerCare Plus, or FoodShare application on behalf of another person. Select 'Yes' or 'No' as appropriate.
- If you answered 'Yes', ensure you have the legal documentation ready to submit to the local agency. If 'No', proceed to fill out your details as the authorized representative.
- Fill in your name, telephone number, address, city, state, zip code, and email address in the designated fields.
- In the authorization section for Medicaid/BadgerCare Plus and FoodShare Wisconsin, enter the applicant's name and confirm your authority to act on their behalf by signing where indicated.
- Ensure that a witness signs your application. If you sign with an 'X', two witnesses are required.
- Finally, review all information for accuracy before submitting the form through our platform.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2013 | 4 Satisfied (49 Votes) |
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What is an appointment of representative form for?
An authorized representative can do any or all of the following on your behalf: Apply for or renew benefits. Report changes to your information. Work with your agency on any matters related to your benefits. File grievances and appeals about your eligibility for programs you are applying for or are enrolled in.
What is the role of an authorized representative?
As a general rule, authorised representatives are required to do the following: Keep records of all advice provided to each client, including details of any discussions, marketing material, FSGs and PDSs provided. Attend any training session as required by the licensee. Refer all complaints to the licensee.
What are the responsibilities of an authorized representative?
Use this form to appoint a representative to act on your behalf for your claim, appeal, grievance or request.
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What are the responsibilities of Authorised representatives?
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