Get State Of Utah Department Of Workforce Services Authorization ...

This guide provides clear and practical steps for users to fill out the State Of Utah Department Of Workforce Services authorization form online. Whether you are a customer or an authorized representative, these instructions will help you navigate the process seamlessly.

Follow the steps to complete the form online:

1. Click ‘Get Form’ button to obtain the authorization form and open it in the online editor.
2. In the first section, enter the customer's name and social security number. Make sure this information is accurate to ensure proper disclosure of medical eligibility information.
3. Next, fill in the case number and date of birth in the designated fields. This helps to identify the correct case associated with the customer.
4. In the authorization section, specify whether you allow the designated individual or organization to receive eligibility information or to act on your behalf. Check only one box based on the authority you wish to grant.
5. Indicate the duration for which the authorization is effective. You can either specify a date or select conditions regarding case denial or closure.
6. Provide the address and phone number of the authorized representative, ensuring accurate contact information is listed for any follow-up.
7. Review the understanding section regarding revocation of authorization and rights under the Notice of Privacy Practices. It is important to be aware of these rights before proceeding.
8. Finally, sign the form as the customer or authorized representative and date it. If someone else is signing on behalf of the customer, provide a description of the authority to serve.
9. Once all information is correctly filled out, you can save your changes, download a copy for your records, print the form, or share it as needed.

Complete your documents online today for a smoother experience.