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  • 2525-ee - Designation Of Authorized Representative - Nevada ... - Dwss Nv

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STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF WELFARE AND SUPPORTIVE SERVICES DESIGNATION OF AUTHORIZED REPRESENTATIVE Case Name: I. Case No.: DESIGNATION OF AUTHORIZED REPRESENTATIVE.

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How to fill out the 2525-EE - Designation Of Authorized Representative - Nevada online

The 2525-EE form, known as the Designation of Authorized Representative, is essential for individuals requesting assistance from Nevada's Division of Welfare and Supportive Services. This guide provides clear, step-by-step instructions to help users complete this form online accurately and efficiently.

Follow the steps to complete the form accurately and efficiently.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Begin by entering the name of the applicant or recipient in the designated field. This should be the full name of the person requesting assistance.
  3. Fill in the case number, which is usually provided in correspondence from the Division of Welfare and Supportive Services.
  4. In the section for Designation of Authorized Representative by Applicant/Recipient, mark whether the selected person is a primary or secondary representative. Ensure that the appropriate boxes are marked according to the role.
  5. The applicant or recipient must provide their signature, along with their date of birth and the date of signing. If they are unable to sign, a family member must complete this portion.
  6. The selected representative must sign in the Statement of Designated Representative section, certifying they agree to act responsibly and provide necessary information for eligibility.
  7. Both the representative's relationship to the applicant and their contact details, including address and telephone number, should be filled in next.
  8. If applicable, complete the section for Designation of Authorized Representative by Other, providing your name, indicating your attempts to contact family, and signing as a primary or secondary representative.
  9. Finally, review all entered information for accuracy and completeness. Once confirmed, users can save changes, download, print, or share the form as needed.

Complete your documents online today for a streamlined experience.

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Contact support

If you need help finding a doctor or scheduling an appointment, please call 1-800-962-8074, TTY 711, Monday through Friday, 8 a.m. to 6 p.m. local time.

Please contact Nevada Medicaid's fiscal agent at (877) 638-3472 for questions regarding enrollment applications, billing, claims, training, etc.

There are four easy ways to make sure your address is updated and correct. Send by email: welfare@dwss.nv.gov, FAX: 702-486-1837 or US mail: DWSS, P.O. Box 15400 Las Vegas, NV 89114 or carry to any office listed at the web address under number 2 above. lease be prepared for extended wait times.

Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.

o English (pressed 1): If you are a recipient calling about Medicaid eligibility, Medicaid benefits or Managed Care HMO changes, please listen for the following options. For persons living in northern Nevada, please call (775) 687-1900. For southern Nevada, please call (702) 668-4200. To repeat, please press 9.

1-800-MEDICARE (1-800-633-4227) Get this form in Spanish.

Check the status of your benefits online at dwss.nv.gov.

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