Get Authorized Representative Appointment Or Removal Form

Filling out the Authorized Representative Appointment Or Removal Form online is a crucial step for providers in managing their New Hampshire Medicaid account effectively. This guide will walk you through the process with clear, step-by-step instructions to ensure that your form is completed accurately.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the form and open it in the online editor.
2. Begin the form by checking the appropriate box to indicate whether you are adding or removing an authorized representative. Remember, a separate form is needed for each representative.
3. Input the NH Medicaid ID or Enrollment ATN in the designated fields. Only one of these identifiers is required.
4. Provide the group name and Doing Business As (DBA) name if applicable. These details help clarify the context of the appointment.
5. Print the name of the authorized representative in the specified section to ensure clarity.
6. Fill in the title or position of the authorized representative. This helps identify their role within the organization.
7. Have the authorized representative sign and date the form in the respective fields.
8. As the individual practitioner or authorized group signee, certify your approval by signing in the designated area.
9. For group appointments, ensure that the signature of an owner, CEO, or equivalent title is included.
10. Enter the printed name and title of the approver, alongside the approver’s signature and date.
11. Once the form is completed, ensure all required fields are filled, then save your changes, and choose to download, print, or share the form as necessary.

Now that you have a comprehensive understanding of how to fill out the form online, proceed to complete your documents with confidence.