[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-306354-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-306354-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","ohio-department-of-medicaid-designation-of-authorized-representative","Ohio Department of Medicaid - Designation of Authorized Representative","","Authorization form for the Ohio Department of Medicaid designating a specific person or company to act as the applicant/recipient’s representative. Section 1 collects applicant and representative details and specifies scope of authority for Medicaid matters, including application or renewal, state hearing representation, correspondence receipt, and discussion of financial and medical information, with PHI handling options. Section 2 authorizes the use and disclosure of protected health information, outlines permitted PHI types, release purposes, expiry and revocation terms, and requires signatures from both parties.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/letters/","Letters",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/ohio-department-of-medicaid-designation-of-authorized-representative/306354/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/ohio-department-of-medicaid-designation-of-authorized-representative/306354.png","ImageObject",442,249,{"name":42,"@type":43},"Berry Peter","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-06","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What does Section 1 authorize an authorized representative to do?","Question",{"text":63,"@type":64},"Section 1 authorizes the designated person or company to represent the applicant/recipient regarding Medicaid matters. It can be limited to selected actions such as application/renewal, state hearing representation, verification to the CDJFS, receiving correspondence, and discussing financial and medical information, including protected health information if covered.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How is protected health information (PHI) handled in this form?",{"text":68,"@type":64},"Section 2 authorizes the CDJFS, the Ohio Department of Medicaid, and their contracted designees to disclose the applicant/recipient’s PHI to the authorized representative. It explains that PHI may include medical, behavioral health, HIV/AIDS, substance abuse care, dental, pharmacy, and other listed categories.",{"name":70,"@type":61,"acceptedAnswer":71},"When does the PHI authorization expire and can it be revoked?",{"text":72,"@type":64},"The authorization expires on the specified date or event, or sooner upon revocation by the applicant/recipient in writing, whichever occurs first. Revocation does not affect information use or disclosure that already occurred before the revocation.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},306354,1790429783,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,114,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":111,"show_sort_weight":112,"slug":113},17,"Forms",40,"forms",{"id":115,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":116,"slug":117},18,30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":115,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":22},1374402524268,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Ohio Department of Medicaid  \nDESIGNATION OF AUTHORIZED REPRESENTATIVE  \nSection 1. (Please print)  \n\n| First Name of Applicant/Recipient | MI | Last Name |  | Medicaid billing number or SSN |\n| --- | --- | --- | --- | --- |\n| Street Address, including Apt. \\# |  | City | Zip | County |\n\nI hereby authorize the following person or company to act as my representative  \n\n| First Name | MI | Last Name | Home Phone |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Title |  | Company | Work Phone |  |  |\n| Mailing Address |  | City | State |  | Zip |\n| I authorize this person or company to represent me regarding Medicaid.\u003Cbr>This authority lasts until   (specify a date or event) , or until it is revoked by me in writing. |  |  |  |  |  |\n| I authorize this person or company to do the following on my behalf:\u003Cbr> Act on my behalf in all matters with the agency [“agency” includes the CDJFS, the Ohio Department of Medicaid (ODM), and ODM’s contracted designees] .\u003Cbr>OR only the specific actions selected below:\u003Cbr> Assist with my application/renewal for benefits  Represent me at a state hearing\u003Cbr> Provide verificationsto the CDJFS on my behalf  Receive and respond to copies of all correspondence  Discuss and receive information regarding my financial and medical information including protected health\u003Cbr>information (PHI)*\u003Cbr> Other (please specify)  \u003Cbr>*NOTE You must complete Section 2 of this form if this authorization is intended to allow the use or disclosure of PHI. |  |  |  |  |  |\n| While this authorization isin effect, all notices sent by the County Department of Job & Family Services and/orthe Ohio Department of Medicaid will also be sent to your authorizedrepresentative. |  |  |  |  |  |\n| Signatures. This form has no effect unless signed by both the person granting authority and by the authorized representative. By signing below, the authorized representative agrees to maintain the confidentiality of any information regarding the applicant/recipient provided by the agency. If the authorized representative is a provider, staff member or volunteer of an organization, then the authorized representative also agrees toadhere to the regulations cited in 42C. F. R. 435. 923(e) . |  |  |  |  |  |\n| Signature of Person Granting Authority |  |  |  | Date |  |\n| Signature of Authorized Representative |  | Title (if employee of an organization) |  | Date |  |\n\nSection 2  \nAuthorization for the Use and Disclosure of Protected Health Information  \nApplicant/Recipient Information  \n\n| First Name | MI | Last Name |  | Date of Birth |\n| --- | --- | --- | --- | --- |\n| Address | City |  | State | Zip Code |\n| Case Number/Medicaid ID |  |  |  |  |\n\nThe CDJFS, the Ohio Department of Medicaid (ODM) andODM’s contracted designees (including Medicaid managed care plans) are authorized to disclose my protected health information (PHI) to my authorized representative designated in Section 1 of this form.  \nI hereby authorize the use or disclosure of my protected health information (PHI) as described below.  \nI understand PHI can include the following types of information, and authorize its disclosure: medical records; substance abuse care; vision care; reproductive care; mental health; communicable disease; pharmacy; HIV/AIDS; dental records; and psychiatric care.  \nThis protected health information may be disclosed  \nThe information is being released forthe following purpose(s)  \nTerms and Conditions  \nBy signing below, I hereby authorize the disclosure of my PHI by the agency. I understand that:  \n• This authorization expires on the following date or event  , or upon revocation by me in writing, whichever occurs first  \n􀁸 If I revoke or cancel this authorization, the revocation is not effective forthe use orfor the disclos ure of my information that has already occurred.  \n• Any information used or disclosed pursuant to this authorization could be re-disclosed by the person or entity receiving the information, andwill likely no longer be protected by ","cbCailDdXbnJKVht","https://ap.wps.com/l/cbCailDdXbnJKVht","pdf",393780,"English","# Designation of Authorized Representative\n## Section 1 (Please print)\n## Section 2\n# Authorization for the Use and Disclosure of Protected Health Information","[{\"question\":\"What does Section 1 authorize an authorized representative to do?\",\"answer\":\"Section 1 authorizes the designated person or company to represent the applicant/recipient regarding Medicaid matters. It can be limited to selected actions such as application/renewal, state hearing representation, verification to the CDJFS, receiving correspondence, and discussing financial and medical information, including protected health information if covered.\"},{\"question\":\"How is protected health information (PHI) handled in this form?\",\"answer\":\"Section 2 authorizes the CDJFS, the Ohio Department of Medicaid, and their contracted designees to disclose the applicant/recipient’s PHI to the authorized representative. It explains that PHI may include medical, behavioral health, HIV/AIDS, substance abuse care, dental, pharmacy, and other listed categories.\"},{\"question\":\"When does the PHI authorization expire and can it be revoked?\",\"answer\":\"The authorization expires on the specified date or event, or sooner upon revocation by the applicant/recipient in writing, whichever occurs first. Revocation does not affect information use or disclosure that already occurred before the revocation.\"}]","Ohio Department of Medicaid - Designation of Authorized Representative | PDF",1789835648]