Authorized Representative Designation Form

name, Last name)

The person or organization below is my authorized representative for all matters related to
my account.
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The person or orga nization below is my authorized representative only to act as my
.
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By signing. you allow this person or organization to get official information about your account and act
for you fer the m:lttcrs yeu sttltcd ~bcvc. Your i'lL.*thoriz~tion ~'il! become cffccti'.'C vJhen VIC rccch:c this
completed form, and it will remain effective until you or your authorized representative tell us that the
authorization has ended.
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Acceptance of Designation

Authorized n!lPr~ntatlve's name (First name, Last name, or OrganiZation name)

Miillllng aooress

State ZIP

Ry <;ignines ynll agrpp to maintain thp r:nnfiripntiality nf any information rpgarrling thp arf\lir:ant or
enrollee that NY State of Health provides, You a/so agree to fulfill all the responsibilities encompassed
within the scope of this authorization as if you were the applicant or enrollee. You also agree to comply
~l.,tith ~ppiicabic state and federai laws c.cnccrninK conflicts or interest.

If you are signing on behalf of an organization, you agree that providers, staff members, and volunteers

affirm that they will comply with applicable state and federal laws concerning conflicts of interest and

confidentiality of information.

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NEED HELP WITH THIS FORM? Call us at 1-855-355-5777.

TTY users should call 1-800-662-1220 or 1-877-662-4886 for TTY in Spanish.

DOH-SasS (09/13)
 Authorized Representative Designation Form
Applicant or Enrollee's name (First name, Last name)

The person or organization below is my authorized representative for all matters related to
my account.
o

n _______ a._ .. ~~~~ -l~~_, _____ ... .. __ ,

~

'SM'9Si n 9 iI YS WH'IU. fill 9 HH jiS..

By signing. you allow this person or organization to get official information about your account and act
for yeu fer the m~ttcrs yeu stated above. Your Iluthorization viiI! become effective when ...le rctcivc this
completed form, and it will remain effective until you or your authorized representative tell us that the

------------
authorization has ended.
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;;;Z~~~~----~:':~=------- Acceptance of Designation
Authorized representative's name (First name. Last name, or Organization name)

Miiumg itoaress

City

Ry <;igning, you ::Igrpp to m::lint::lin thp r:nnflrIPoti"Uty of ::Iny inform::ltion rpe"rding thp ::Ip~lil':::Int or
enrollee that NY State of Health provides. You also agree to-fulfill all the responsibilities encompassed
within the scope of this authorization as if you were the appficant or enroHee. You also agree to comply
with appiicaoie siate and feaerai iaws concerning conflicts of inter.est.

If you are signing on behalf of an organization, you agree that providers, staff members, and volunteers

affirm that they will comply with applicable state and federal laws concernina conflicts of interest and

confidentiality of information.
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NEED HELP WITH THIS FORM? Call us at 1-855-355-5777.

m users should call 1-800-662-1220 or 1-877-662-4886 form in Spanish.