Get Tx H1003 2011

Texas Health and Human Services Commission Form H1003 March 2011 Appointment of an Authorized Representative To Allow Another Person to Act for You An authorized representative can help you with your benefits case. You don t need an authorized representative to get Medicaid or to be admitted to a nursing home or other place of care. 1. Contact Information Client Name or Applicant Medicaid No* Name of person who can act for you authorized representative Telephone number of person who can act for you authorized representative Address of person who can act for you authorized representative 2. The authorized representative is your Power of attorney Parent Court-appointed guardian give end date Other tell us about your relationship 3. How long will this person be able to act for you Give end date mm/dd/yy / 4. I would like the person acting for me to be able to do the following check all that apply Fill out an application form* Check the status of Medicaid application or renewals. Fill out renewal form* Give the state all forms and facts that are needed to get benefits. Report changes. All of the above. 5. The person acting for me cannot do the following for me explain in writing 6. Sign below if you want the person you are listing on this form to be your authorized representative. This person will be your authorized representative only for the time period of this form see Question 3. You can have only one person at a time act for you as your authorized representative. I certify under penalty of perjury that the information I have provided on this application is true and complete to the best of my knowledge. If it is not I may be subject to criminal prosecution* Person who agrees to be the authorized representative This person must age 18 or older. You don t need an authorized representative to get Medicaid or to be admitted to a nursing home or other place of care. 1. Contact Information Client Name or Applicant Medicaid No* Name of person who can act for you authorized representative Telephone number of person who can act for you authorized representative Address of person who can act for you authorized representative 2. 1. Contact Information Client Name or Applicant Medicaid No* Name of person who can act for you authorized representative Telephone number of person who can act for you authorized representative Address of person who can act for you authorized representative 2. The authorized representative is your Power of attorney Parent Court-appointed guardian give end date Other tell us about your relationship 3. The authorized representative is your Power of attorney Parent Court-appointed guardian give end date Other tell us about your relationship 3. How long will this person be able to act for you Give end date mm/dd/yy / 4. I would like the person acting for me to be able to do the following check all that apply Fill out an application form* Check the status of Medicaid application or renewals. How long will this person be able to act for you Give end date mm/dd/yy / 4. I would like the person acting for me to be able to do the following check all that apply Fill out an application form* Check the status of Medicaid application or renewals. Fill out renewal form* Give the state all forms and facts that are needed to get benefits. Report changes. .