This form is effective for one (1) year from date of signature. Visit our web page at esd.maricopa.gov.Maricopa County Wellness Works Program invites you to complete the following template, sign the authorization form, and submit to Wellness Works. Use this form to designate an agent to act on your behalf on any matter dealing with the valuation and classification of your property. Instructions for completing this form: 1. Download and save this form on your computer before completing it. 2. 602-258-4488​​ Please fill out the Authorization form below. Request forms and charges for public records materials. HIPAA Patient Authorization (PDF). Step 2: Required documents to upload with the application:.