Texas Health and Human Services Commission Form H1003 March 2011 Appointment of an Authorized Representative To Allow Another Person to Act for You An authorized representative can help you with your benefits case. You don t need an authorized representative to get Medicaid or to be admitted to a nursing home or other place of care. 1. Contact Information Client Name or Applicant Medicaid No* Name of person who can act for you authorized representative Telephone number of person who can act for you authorized representative Address of person who can act for you authorized representative 2. The authorized representative is your Power of attorney Parent Court-appointed guardian give end date Other tell us about your relationship 3. How long will this person be able to act for you Give end date mm/dd/yy / 4. I would like the person acting for me to be able to do the following check all that apply Fill out an application form* Check the status of Medicaid application or renewals. Fill out ....
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How to fill out the TX H1003 online
The TX H1003 form allows an individual to designate someone to act as their authorized representative for benefits-related matters. This guide will walk you through the process of filling out the form online, ensuring that your chosen representative can assist you effectively.
Follow the steps to complete the TX H1003 online
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In the first section, provide your client name or applicant's name, along with the Medicaid number. Fill in the name, telephone number, and address of the person you are appointing as your authorized representative.
- Indicate the relationship of the authorized representative to you by selecting one option from the provided choices, such as power of attorney or parent. If applicable, include the end date for a court-appointed guardian.
- Specify how long this person will be able to act for you by entering an end date in the designated field.
- Check all the boxes indicating what actions the authorized representative is allowed to perform on your behalf, such as filling out application forms or reporting changes.
- Clearly outline any actions that the authorized representative is not permitted to do in the explanation section provided.
- Sign the form to affirm that you wish the designated person to be your authorized representative for the specified time period. The authorized representative must also sign the form, certifying that they are 18 years or older.
- Finally, save your changes, download a copy of the completed form, print it out, or share it as needed.
Complete your TX H1003 form online today to ensure effective representation for your benefits case.
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