Designation of authorized representative




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IM-194 (Rev. 01/2010)
Lorain County Department of Job and Family Services

DESIGNATION OF AUTHORIZED REPRESENTATIVE


Case Number






First Name of Applicant/Recipient

MI

Last Name

Medicaid billing # or SSN













Street Address, including Apt #

City

Zip

County










#47 / LORAIN


I hereby authorize the following person or company to act as my representative:


First Name

MI

Last Name

Home Phone













Title

Company

Work Phone










Mailing Address

City

State

Zip














I authorize this person or company to represent me regarding:





Food Assistance




Cash Assistance




Medicaid




Child Care




Other - list:








This authority lasts until:





My application has been approved




I rescind this authority, or appoint a new representative




Other (please specify a date or action)








I authorize this person or company to do the following on my behalf:





Take any action that may be needed to ensure that I receive or continue to receive the benefits indicated above


OR only the specific actions selected below





Present my application for benefits




Collect my medical records




Provide verifications to the CDJFS on my behalf




Protective Payee on my cash benefits




Represent me at a state hearing




To receive benefits on my behalf




Receive and respond to copies of all correspondence regarding my application




Other (please specify)








While this authorization is in effect, all notices sent by the County Department of Job & Family Services or the Ohio Department of Job & Family Services will also be sent to your authorized representative.



Signatures. This form has no effect unless signed by the person granting authority and by the authorized representative or an employee of the company appointed to be the authorized representative.


Signature of Person Granting Authority

Date







Signature of Authorized Representative

Title (if employee of authorized company)

Date











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