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 (if applicable) to this form and sign and date below. 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 SECTION D AUTHORIZATION TO APPLY FOR MEDICAID ON APPLICANT’S BEHALF INSTRUCTIONS: If the applicant would like to provide the below authorization allowing you to represent him/her in applying for and/or renewing Medicaid, the applicant or his/her legal representative or spouse must sign the authorization below.
Appears in 21 contracts
Samples: Admission Agreement, Admission Agreement, Admission Agreement
