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Click ‘Get Form’ to open the Authorized Representative Appointment or Removal Form in our editor.
Begin by selecting whether you are adding or removing an Authorized Representative by checking the appropriate box at the top of the form.
Fill in your NH Medicaid ID or Enrollment ATN, along with the Group Name and Doing Business As (DBA) Name if applicable.
In the next section, print the name of the Authorized Representative, their title/position, and ensure they sign and date the form.
If applicable, have the group owner or authorized individual sign in the designated area, providing their printed name, title/position, and date.
Review all entries for accuracy before saving your changes. Once completed, upload this authorization page to your Enrollment Application or Revalidation Application.

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2018	4.8 Satisfied (46 Votes)

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What is the purpose of an aor?

An Agent of Record (AOR) is an individual or company authorized to manage insurance policies, employee benefits, or related services on your behalf. Businesses use AORs to simplify coverage management, advocate during claims, assess risks, and ensure ongoing compliance with insurance regulations.

What is an aor form for?

Use this form to appoint a representative to act on your behalf for your claim, appeal, grievance or request.

How do I remove an authorized representative from Social Security?

Revocation of a Representatives Appointment You must sign and date your revocation and file it with us either in-person at your local field office, mail it, or fax it to us. You should also tell your representative. Once you revoke the appointment, we will no longer deal with the named representative.