The following “Authorized Representative for Health Coverage Form” is required with all Financial Assistance Applications. We have prefilled out the sections that are required, but need you to review the information and sign off so our partner, ClaimAid, can apply for health insurance coverage or other resources that may be available to cover the cost of your care.
Authorized Representative for Health Coverage Form
If you want someone to act on your behalf in applying for benefits and/or act for you on an ongoing basis, this form must be completed. Be sure to select the function(s) that the representative is being authorized to do. You can select more than one representative and choose the same or different functions. The representative may be an individual or an organization. Complete ONE form per authorized representative. Both you and your representative must sign and date this form.
I authorize this representative to act for me in taking care of the functions and program eligibility process which I have checked above. (If applicant/recipient is medically incapable to sign authorization, provide medical documentation.) I understand that I am responsible for the information anyone acting as my authorized representative gives, including any information that may be incorrect. I also understand that if at any time I wish to stop the person(s) I chose from being my authorized representative, it is my responsibility to contact the Division of Family Resources.