View Authorized Representative Form Gif. When you've finished filling out the form, save it, print it, and mail it, or fax it to the health insurance marketplace at the location shown on the form. My authorized representative in my application for medicaid led with the eligibility determining agency (eda) or new jersey division of medical assistance and health services (dmahs) i authorize my representative to take any action which may be necessary to establish my eligibility for nj familycare.
I authorize the person named below to be my personal representative, to act on my behalf to make all this appointment will remain in effect for 1 year from signature unless i specify an earlier expiration date here:
You can submit this form if you would like to designate an authorized representative to act on your behalf. Right click for pc or ctrl + click for mac on the pdf link and click save link as from the menu. You may want to be particular in creating this form so as to avoid any misunderstandings. The dealership referenced below wishes to authorize the following person as an authorized representative at all of national powersport auctions locations as of the date listed below.