REASON FOR SUBMISSION. INSTRUCTIONS: If you are signing a Medicaid application on behalf of the applicant, you must provide the authorization/legal document authorizing you to apply on the applicant’s behalf OR attest that the applicant is incompetent or incapacitated. Please check the appropriate boxes below. Attach the authorization I have authorization to apply for Medicaid on behalf of the applicant. (Check the box for the type of authorization you have and submit the authorization OR complete Section D below.) Guardianship Document Power of Attorney (POA) Document Other Written Authorization (Specify) I attest that the applicant is incompetent or incapacitated. S/he is unable to sign the application herself/himself and is unable to provide written consent for me to apply on his/her behalf. Signature of Person Completing This Form Date Signed
REASON FOR SUBMISSION. Indicate your reason for completing this form by checking the appropriate box: New EFT authorization or change to your account information. If you are authorizing EFT payments to the home office of a chain organization of which you are a member, you must attach a letter authorizing the contractor to make payment due the provider of service to the account maintained by the home office of the chain organization. The letter must be signed by an authorized official of the provider of service and an authorized official of the chain home office.
REASON FOR SUBMISSION. Indicate your reason for completing this form by checking the appropriate box: New EFT enrollment, a change to your EFT enrollment account information, or cancellation of your EFT enrollment.
REASON FOR SUBMISSION. Indicate your reason for completing this form by checking the appropriate box: New EFT enrollment, change to your EFT enrollment account information, or cancellation of your EFT enrollment. If you are authorizing EFT payments to the home office of a chain organization of which you are a member, you must attach a letter authorizing the contractor to make payment due the provider of service to the account maintained by the home office of the chain organization. The letter must be signed by an authorized official of the provider of service and an authorized official of the chain home office.
REASON FOR SUBMISSION. Reason for Submission:
REASON FOR SUBMISSION. See Instructions on Page 2 Document Included: Voided Check Bank Letter PART II: ACCOUNT HOLDER INFORMATION- See Instructions on Page 2
REASON FOR SUBMISSION. See Instructions on Page 2
REASON FOR SUBMISSION. See Instructions on Page 3 New Enrollment Change Enrollment Cancel Enrollment Document Included: Voided Check Bank Letter Account Holder Legal Name: DBA Name if different from above: Legal Address: number, street, and apt. or suite no. City: State: Zip Code: Account Holder Tax Identification Number (9 digits EIN or SSN) EIN: SSN:
REASON FOR SUBMISSION. Reason for Submission: ❑ New EFT Authorization ❑ Revision to Current Authorization (e.g. account or bank changes) Chain Home Office: Organization ❑ Check here if EFT payment is being made to the Home Office of Chain (Attach letter Authorizing EFT payment to Chain Home Office)
REASON FOR SUBMISSION. Must select one from below
