Get Designation Of Responsible Representative Form - Louisiana ...

Completing the Designation Of Responsible Representative Form in Louisiana is an essential step for individuals seeking assistance in their home and community-based services. This guide provides clear and supportive instructions to help you fill out the form accurately and efficiently online.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access and open the Designation Of Responsible Representative Form in your preferred online platform.
2. Begin by entering the requestor/applicant/participant's name. Make sure to print the name clearly in the designated field.
3. Input the last four digits of the social security number (SSN) of the requestor/applicant/participant. Be careful to enter this information accurately.
4. Fill in the date of birth (DOB) for the requestor/applicant/participant, ensuring it follows the required format.
5. In the section labeled I, insert the printed name of the participant, affirming their understanding of the responsibilities associated with having a representative.
6. Designate a responsible representative by providing their name, last four digits of their SSN, and DOB, ensuring that this person is not a paid direct service worker.
7. Record the relationship of the responsible representative to the requestor/applicant/participant, along with their address and both home and alternate phone numbers.
8. If applicable, repeat the previous step for a second responsible representative by completing their details in the same manner.
9. The requestor/applicant/participant must sign the form, followed by the date, confirming that the information is accurate.
10. Include signatures from two witnesses as needed, ensuring that one of them is designated by the Office of Aging and Adult Services.
11. Once you have filled out the entire form, ensure all information is accurate. Save your changes, then download, print, or share the completed form as required.

Take the next step in your application process by completing the Designation Of Responsible Representative Form online today.