Get State Form 55366

Filling out State Form 55366 online is an essential process for designating an authorized representative for health coverage benefits. This guide provides clear, step-by-step instructions to ensure users can complete the form accurately and efficiently.

Follow the steps to fill out State Form 55366 correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section 1, indicate if you want someone to act on your behalf in applying for benefits. Ensure to select the functions that your representative will be authorized to perform; you may choose multiple functions. Remember to complete one form for each authorized representative, and both you and your representative must sign and date the form.
3. Move to Section 2, where you will provide the name of the representative clearly. Check the appropriate box regarding their association with the applicant or recipient. Options include attorney, eligibility assistance company, friend, family, institution of residence, waiver case manager, or specify another association.
4. Fill out the mailing address of the representative, including the street number, city, state, and ZIP code.
5. Select the function(s) that the authorized representative will perform, which may include applying for health coverage and ongoing responsibilities. Ensure to detail the specific functions checked.
6. In the signature and date fields, the authorized representative needs to sign and date the form, also providing a phone number for contact.
7. Section 3 requires the applicant or recipient to agree by signing the form, stating their understanding of the authority granted and the responsibility they hold. Be sure to provide the applicant or recipient's name, signature, date, and case number if applicable.
8. Finally, review the completed form for accuracy, ensuring all necessary sections are filled out, then save your changes. You can choose to download, print, or share the form as needed.

Complete your documents online today to streamline your applications.