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Authorized Representative Form


In order to obtain information about a specific case from the Division of Family Resources (DFR) you must be an authorized representative. For the state to discuss your case or history with your representative, you will need to give permission to the state. The following list describes the permissions required:

  • If you want someone to act on your behalf in applying for benefits or act for you on an ongoing basis in regards to your case, you must complete an Authorized Representative for Health Coverage Form. You can get this form directly from DFR or via the link below. You can also give permission for your representative verbally by calling DFR.
  • If you want DFR to be able to share your personal or health information with others, you must complete the Authorization for Disclosure of Personal and Health Information Form.

Authorization for Disclosure of Personal and Health Information Form

  • If you want someone to represent you concerning services received under Medicaid, including the sharing of your protected health information, you must complete the IHCP Personal Representative Authorization Form.

IHCP Personal Representative Authorization Form

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