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Virginia medicaid authorized representative form

AUTHORIZED REPRESENTATIVE FORM CLIENT S NAME: DATE OF ... - dmas virginia 2026

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The document is an Authorized Representative Form that allows a client to appoint a representative to act on their behalf in appealing a decision regarding the denial, termination, or reduction of Medicaid or FAMIS benefits. It includes sections for client information, details about the appeal, and the representative's contact information. The form emphasizes that signing is voluntary and does not waive the client's rights or financial obligations. It also addresses provisions for clients who are physically or mentally unable to sign.

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Click ‘Get Form’ to open the AUTHORIZED REPRESENTATIVE FORM in the editor.
Begin by entering the CLIENT’S NAME and SSN in the designated fields at the top of the form.
Fill in the DATE OF BIRTH and CASE NUMBER to ensure accurate identification.
Provide your AREA CODE and DAYTIME PHONE NUMBER for contact purposes.
Indicate your intention to appeal by filling in the name of the agency and the date of action taken regarding your Medicaid or FAMIS benefits.
Appoint your AUTHORIZED REPRESENTATIVE by entering their name and address, along with their contact number.
Review the authorization statement carefully, ensuring you understand your rights before signing as either a client or parent of a minor child.
If applicable, have your authorized representative sign if you are physically unable to do so, providing a description of incapacity if necessary.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Who handles Medicaid in Virginia?

The Department of Medical Assistance Services (DMAS) administers health care services, like Medicaid, for qualifying Virginians. DMAS is a part of the Executive branch of state government.

What does Virginia DMAS stand for?

DMAS or the department means the Virginia Department of Medical Assistance Services. DMAS-225 means the Medicaid Communication form used for the provider and the DSS eligibility worker to report changes including requests for adjustments to the patient pay.

Who is the authorized representative for Medicaid in Virginia?

The authorized representative of an incapacitated individual shall be the individuals legally appointed guardian or conservator. C. A competent individual may sign an application on his own behalf or may designate anyone to be his authorized representative to file a Medicaid application on his behalf.

How do I get approved for Medicaid in VA?

Apply Online at: Call Cover Virginia at 1-855-242-8282 to apply on. the phone Monday-Friday 8:00 AM-7:00 PM and. .dss.virginia.gov/benefit/medicala. ssistance/forms.cgi. You can find the address and phone number. .

Who is a legally authorized representative in Virginia?

Virginia law 32.1-162.16 defines a legally authorized representative in the following specified order of priority for adults: (a) the agent appointed under an advance directive, as defined in 54.1-2982, executed by the prospective subject, provided the advance directive authorizes the agent to make decisions

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What is the phone number for Medicaid prior authorization in Virginia?

Please contact the Provider Helpline at 1-800-552-8627 (in-state long distance) or (804) 786-6273 (local and out of state customers) for services that are currently authorized by DMAS Medical Support Unit; Certain waiver enrollment/service authorizations [pdf] Maintained by DMAS Office of Community Living.

What is Virginia DMAS 225 form?

Prior authorization is required for some out-of-network providers, outpatient care and planned hospital admissions. We dont require PA for emergency care. You can find a current list of the services that need PA on the Provider Portal.