USVI Public Records

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This form is used to designate an authorized representative to act on your behalf for Medicaid certification and reporting purposes. Your representative may be an adult individual, a company, or an organization. Complete all applicable sections, including representative contact information and scope of authority. Submit this completed form to the Medicaid office in person, by mail, or by email. Be sure to have the appropriate identification documents present at the time of submission. Required Documentation: • Authorized Representative must provide a Picture ID • Authorized Representative must provide an executed and notarized Power of Attorney • Social Security Card The client and/or authorized representative may revoke this authorization at any time by providing a written statement to the Medicaid office. Authorization of Representative: I, , understand that I have the right to designate an adult as my autho- rized representative for Medicaid purposes. I hereby designate the following individual (or entity) to act on my behalf for certification and/or reporting purposes with the understanding that I would be held liable for any issuance resulting from false information given by them. Authorized Representative Form For use with Medicaid applications Applicant Name Case Number Date Date of Birth Home Address Mailing Address Phone Number Email Applicant Name Home Address Phone Number Email Relationship to Client FOR OFFICE USE ONLY Received by: Date Scope of Authorization (check all that apply): 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; Act on behalf of the applicant or beneficiary in all other matters with the agency. Client Signature Date Client Signature Date Client Printed Name Auth Rep Signature Phone Number Email OR Acceptance of Representative: I, , understand that as an authorized representative I may act on the individual’s behalf for Medicaid certification and reporting purposes upon submission of this complet- ed form. I agree to maintain the confidentiality of any information regarding the applicant or beneficiary provided by the agency. Auth Rep Signature Mailing Address Phone Number Email Disclaimer: We do not discriminate on the basis of race, ethnicity, color, national origin, religion, sex, age, or disability. Free language assistance services are available for people whose primary language is not English. We also provide free aids and services to assist with communicating the information effectively (such as interpreters, captioning, Braille, or large print). If you need these services, please contact us by phone or email. St Thomas/St. John District: 340-774-0930 ext. 4104 or sttjmap@dhs.vi.gov | St. Croix: 340-772-7100 or stxmap@dhs.vi.gov Privacy Notice: The information provided on this form will be used only for purposes of determining and verifying Medicaid eligibility. Your information is protected under state and federal privacy laws. Date Date Client Perjury Statement: Under penalty of perjury, I certify that the information presented in this document is true and accurate to the best of my knowledge. By signing below, I understand that providing false statements may result in termination, denial, or recovery of benefits. SIGN SIGN SIGN SIGN