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AUTHORIZED REPRESENTATIVE FORM CLIENT S NAME: DATE OF ... - dmas virginia 2026
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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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May 21, 2021 You can use this form to appoint an individual or organization to act as your authorized representative. I understand: ▫ I can represent myself.Read more