Authorized Representative/Disclosure forms
Establishing an Authorized Representative with the state
You may wish to authorize an advocate or representative to communicate with the state’s eligibility staff, assist you with filing or processing your application, receive notices on your behalf and/or help you with the annual redetermination process. This is done by completing an Authorized Representative for Health Coverage form (state form 55366) and filing it with the state. This form can be downloaded here: https://forms.in.gov/Download.aspx?id=11310. The form needs to be signed by you and the person you authorize as your representative. It should then be filed with the state by fax to 800-403-0864 or delivered by mail or in person to your local county office.
More information about authorizing a representative to serve on your behalf including the responsibilities of an authorized representative is available here.
Health plan disclosure forms
Additionally, each of the health plans may require its own form to be submitted in order for anyone to be authorized to act or communicate on a member’s behalf. Please access the appropriate forms below, sign and return them as noted.
- Anthem:
Member authorization forms (with instructions) in English and Spanish.
These forms should be completed and submitted to Anthem at: - MDwise:
https://www.mdwise.org/Uploads/Public/Documents/MDwise/HIP-member-consentform_2021.pdf
This form should be completed and submitted to MDwise at:
MDwise Healthy Indiana Plan
P.O. Box 44236
Indianapolis, IN 46244-0236 - MHS:
https://www.mhsindiana.com/content/dam/centene/mhsindiana/medicaid/pdfs/HIPAA-Authorization-to-Disclose-PHI.pdf
This form should be completed and submitted to MHS at:
MHS
1099 N. Meridian St., Suite 400
Indianapolis, IN 46204
Member Privacy Unit
PO Box 62509
Virginia Beach, VA. 23466
Fax: 888-562-5165
