Medicaid Authorized Representative

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The intent of this message is to provide the Managed Long Term Care plans with information concerning requesting Personal Health and Medicaid case information for potential and current enrollees.

DOH–5247 – Medicaid Authorized Representative Designation/Change Request allows a consumer to assign, change or discontinue an authorized representative at renewal or at any time following application. This form also allows the plan to assist the consumer with their Medicaid application and renewal.