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Get TX H1003 2015

Form H1003 April 2015 Appointment of an Authorized Representative To Allow Another Person to Act for You If you want you can give someone the right to act for you an authorized representative. That person can Give and get facts for this application* Take any action needed for the application process. This includes appealing an HHSC decision* You can have only one authorized representative for all your benefits from HHSC. If you want to change your authorized representative 1 log in to your account on YourTexasBenefits. com and report a change or 2 call 2-1-1 after you pick a language press 2. If you re a legally appointed representative for someone on this application send proof with this form* 1. Contact Information Client name or Applicant Case number Name of person who can act for you authorized representative Organization Address of person who can act for you authorized representative Telephone number of person who can act for you authorized representative 2. The authorized representative is your Power of attorney Court-appointed guardian give end date Other tell us about your relationship 3. Sign below if you want the person you are listing on this form to be your authorized representative. I certify under penalty of perjury that the information I have provided on this application is true and complete to the best of my knowledge. If it is not I may be subject to criminal prosecution* Person who agrees to be the authorized representative This person must be age 18 or older. That person can Give and get facts for this application* Take any action needed for the application process. This includes appealing an HHSC decision* You can have only one authorized representative for all your benefits from HHSC. This includes appealing an HHSC decision* You can have only one authorized representative for all your benefits from HHSC. If you want to change your authorized representative 1 log in to your account on YourTexasBenefits. If you want to change your authorized representative 1 log in to your account on YourTexasBenefits. com and report a change or 2 call 2-1-1 after you pick a language press 2. If you re a legally appointed representative for someone on this application send proof with this form* 1. com and report a change or 2 call 2-1-1 after you pick a language press 2. If you re a legally appointed representative for someone on this application send proof with this form* 1. Contact Information Client name or Applicant Case number Name of person who can act for you authorized representative Organization Address of person who can act for you authorized representative Telephone number of person who can act for you authorized representative 2. Contact Information Client name or Applicant Case number Name of person who can act for you authorized representative Organization Address of person who can act for you authorized representative Telephone number of person who can act for you authorized representative 2. The authorized representative is your Power of attorney Court-appointed guardian give end date Other tell us about your relationship 3. .

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