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Certificate Of Authorized Representative. , the Medicare beneficiary, the provider or the supplier):.A completed Paid Family and Medical Leave designated authorized representative form;. A completed Paid Family and Medical Leave designated authorized representative form;. Authorized Representative Identity Verification Form. Certification of designated representative. An authorized representative is someone you choose to act on your behalf with Maryland Health Connection, like a family member or other trusted person. Users who wish to complete major source (Title V) RADIUS. Duly Authorized Representative Application Form. "Us" and "SSA" means the Social Security Administration.