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

1. Click ‘Get Form’ to open the AUTHORIZED REPRESENTATIVE FORM in the editor.
2. Begin by entering the CLIENT’S NAME and SSN in the designated fields at the top of the form.
3. Fill in the DATE OF BIRTH and CASE NUMBER to ensure accurate identification.
4. Provide your AREA CODE and DAYTIME PHONE NUMBER for contact purposes.
5. 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.
6. Appoint your AUTHORIZED REPRESENTATIVE by entering their name and address, along with their contact number.
7. Review the authorization statement carefully, ensuring you understand your rights before signing as either a client or parent of a minor child.
8. 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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