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State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND MEDICAL ASSISTANCE PROGRAM

REPRESENTATIVE’S STATEMENT

PLEASE COMPLETE THE APPROPRIATE SECTION BELOW

OR

DES 2004 (LTC) 11/03

I,

do hereby consent to allow

________________________________________________ to act as my Authorized Representative. In such

capacity he/she shares the responsibility, with me, of providing accurate and timely information to the

Department of Social Services as needed/requested in order to determine Medical Assistance eligibility.

APPLICANT’S SIGNATURE

DATE _______________________

REPRESENTATIVE’S SIGNATURE

DATE_______________________

I,

do hereby consent to fully represent

. I further realize that, as the full Representative, I am fully

responsible for providing timely and accurate information to the

Department of Social

Services as requested/needed.

REPRESENTATIVE’S SIGNATURE

DATE