GIS 17 MA/017: Introduction to Form DOH-5247 - Medicaid Authorized Representative Designation/Change Request

The purpose of this General Information System message is to introduce a new form entitled, "Medicaid Authorized Representative Designation/Change Request" (DOH-5247). The DOH-5247 (see Attachment) may be used when a consumer wishes to assign, change or discontinue an authorized representative at renewal or at any time following application.

In 2010, the Access NY Health Care application (DOH-4220) was revised to provide consumers with the opportunity to identify and authorize a representative. As instructed in 10 OHIP/ADM-5, "Revised DOH-4220: Access NY Health Care Application and Release of DOH-4495A: Access NY Supplement A," an applicant can identify the specific role(s) that an authorized representative can have. The authorized representative can apply for and/or renew Medicaid for the consumer, discuss the consumer’s Medicaid application or case with the local district, if needed, and/or get copies of notices and agency correspondence. If authorization is provided to a representative on the DOH-4220 (Section A – Applicant’s Information) and the applicant is the person signing the application, there is no need for a separate document authorizing a representative. However, if the representative is the person signing the application, the district must obtain a separate authorization from the applicant or evidence of legal guardianship or a power of attorney. Once received, the designation of an authorized representative continues until it is revoked by the consumer or Medicaid coverage ends. If an applicant indicates that another person should get copies of notices and correspondence, the district must send the notices and correspondence to both the applicant and that person

In accordance with federal regulations at 42 CFR 435.923, consumers must be permitted to assign an authorized representative at the time of application and at other times. When a consumer contacts a district stating he or she wishes to appoint an authorized representative or change a current authorized representative, the local district may print a copy of the DOH-5247 from the electronic Library of Official Documents (http://health.state.nyenet/revldssforms.htm). The district would then mail the DOH-5247 to the consumer to complete and return. As a reminder, the district must maintain a copy of all authorized representative forms in the case record.

A question and answer regarding authorized representatives will be placed on the Department of Health internet web site for consumers with a link to the DOH-5247.

Please direct any questions to your local district support liaison.