WebDec 1, 2014 · Effective August 17, 2015. Designating an authorized representative (AREP). A person may designate an AREP to act on his or her behalf in eligibility-related interactions with the medicaid agency by completing the agency's Authorized Representative Designation Form (DSHS 14-532), or through any of the methods … WebCareSource Indiana Managed Health Services (MHS) MDwise The care of Hoosier Healthwise members is managed through a network of primary medical providers, …
Member Consent/HIPAA Authorization Form
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Personal Representatives HHS.gov
WebTo request enrollment in a Medicaid home and community-based services (HCBS) waiver, please complete and submit this form to your local county Department of Job and Family Services (CDJFS) office. For information about your local CDJFS office location, call the Medicaid consumer hotline at (800) 324- 8680 or visit Web11 - Form 5588 - Level of Care Placement Form: PDF: EDWP CASE MGMT: 100.2: 03/30/2024 : 11 - Form 5588 - Level of Care Placement Form - Instructions: PDF: … WebDFR: Authorized representative for SNAP (food assistance and cash assistance) DFR: Authorization for disclosure of personal and health information DFR: Becoming an … proform 1450 treadmill