Designation of Authorized Representative - New Mexico Human

Designation of Authorized Representative - New Mexico Human

New Mexico Human Services Department DESIGNATION OF AGENT TO ACT AS AUTHORIZED REPRESENTATIVE FOR MEDICAL ASSISTANCE Case Name: Case Number : Geo/A...

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New Mexico Human Services Department

DESIGNATION OF AGENT TO ACT AS AUTHORIZED REPRESENTATIVE FOR MEDICAL ASSISTANCE Case Name:

Case Number :

Geo/Admin :

A. Authorization: I (applicant, recipient or legal representative): Name of Applicant/ Recipient or Representative: Mailing Address:

Telephone Number:

City, State, ZIP Code:

Fax Number:

authorize (by initialing below) the representative named below to:

____ ____ ____ ____

sign an application on the applicant’s behalf; complete and submit a renewal form; receive copies of the applicant or beneficiary’s notices and other communications from the agency; and act on behalf of the applicant or beneficiary in all other matters with the agency.

Name and Relationship of Representative:

Name

Relationship

Mailing Address:

Telephone Number:

City, State, ZIP Code:

Fax Number:

B. Expiration of Request: This authorization will be in (Date) to (Date) effect from: This authorization shall Event: Date: expire upon: I understand that this authorization will expire on the date/event above or 18 months from the date on which it was signed; whichever is earlier. I understand if I do not specify an expiration date this authorization will expire 18 months from the date on which it was signed.

I understand that I may revoke this authorization at any time in writing.

C. Statement of Understanding and Agreement:

• I understand that the representative I have named is authorized to act on my behalf for applying for, or renewing my Medical assistance. • I understand that the representative I have named is authorized to receive notifications from the Human Services Department about my benefits or eligibility. • I understand that the representative I have named is authorized to act on my behalf in all other matters with the Human Services Department. • I understand that the representative I have named is authorized to provide medical records to, receive them from, the Human Services Department in order to determine my eligibility for Medical assistance. • I understand I have a right to revoke this authorization in writing at any time and that the Human Services Department cannot take back any uses or disclosures already made before an authorization is cancelled.

 Signature of Individual or Personal Representative Authorized by Law

Date

If signed by Personal Representative, basis of authority: ____________________________________

D. Agreement by Designee Authorized to Act on Applicant’s/Recipient’s Behalf: I, as the Authorized Representative, affirm and agree to be legally bound to maintain the confidentiality of any information regarding the applicant or beneficiary, shall not reassign any provider claims, if applicable, and shall adhere to all requirements set forth in 42 CFR 435.923.

 Signature of Authorized Representative

Date

MAD 344 Revised 02/01/2014 Distribution: Original – Case Record; Copy – Client

Important Information about Authorization The New Mexico Human Services Department’s (HSD’s) policies and your rights are more fully described in HSD’s Notice of Privacy Practices, available by writing to the address at the bottom of this page. Your right to file a privacy complaint and to revoke an authorization You may contact the Privacy Office listed below if you want to file a complaint or to report a problem about how HSD has used or disclosed information about you. Your benefits will not be affected by any complaints you make. If you file a complaint, cooperate in any investigation, or refuse to agree to something that you believe to be unlawful, it will not be held against you. You may also write to this address to revoke an authorization you gave to HSD. New Mexico Human Services Department HIPAA Privacy Officer P.O. Box 2348 Santa Fe, NM 87504-2348 Phone: 1-888-997-2583

MAD 344 Revised 02/01/2014 Page 2 of 2