Get IA DHS 470-5526 2018
Rm to appoint an individual, organization, or provider to act on your behalf during the appeals process. The member and the authorized representative must both sign this form. Legal documentation such as a court order establishing legal guardianship or a power of attorney can be submitted instead to designate a representative. Appellant Information First and Last Name Case Number Date of Birth Medicaid ID Number Telephone Number Parent s Name, if appellant is minor (under age 18) Brief Exp.
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