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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL A-120 AUTHORIZED REPRESENTATIVE (A/R) Customers may designate anyone they choose to act on their behalf by completing the A/R section on the application, using the Authorized Representative Form 2525, OR they may complete and sign Form 2451 “Authorization for Release of Information” allowing the Division to release case information to individuals or agencies/organizations. A Court Order of Guardianship or a valid Power of Attorney is acceptable as a designation of authorized representation. Power of Attorney status may vary with each customer. Obtain a completed Form 2525 for the individual case member designating the Power of Attorney as an authorized representative. The authority to act as an A/R is valid until such time as the customer notifies the agency that the A/R is no longer authorized to act on his/her behalf, or the legal authority upon which their status was based has changed. The A/R may also notify the Division that they no longer wish to be listed as an authorized representative for the customer. The A/R must be:  An adult, 18 years of age or older.  Designated in writing with a valid signature by the customer or (if incapacitated) someone acting responsibly for the customer. This designation must include the name and address of the person chosen as an A/R, the signature of the household member making the choice, and the date.  Willing to take responsibility for fulfilling all responsibilities encompassed within the scope of the authorized representation, to the same extent as the individual he/she represents.  Able to maintain, or be legally bound to maintain, the confidentiality of any information regarding the applicant or beneficiary provided by the agency. NOTE: Valid signatures from the customer or responsible person may be handwritten and submitted in person, via mail, or through commonly available electronic means (i.e. facsimile, email, internet website, etc…) accepted by DWSS. Electronic signatures made as part of a DWSS Access Nevada application, and telephonically recorded signatures are also acceptable. If the designation is made by a household member who is unable to or cannot sign, their mark must be witnessed by someone other than the A/R. With each subsequent reapplication, a new request, Form 2525 and/or Release of Information is required. It is not necessary at redetermination, unless the customer indicates a change of A/R. Division of Welfare and Supportive A-120 Medical Assistance Manual MEDICAL ASSISTANCE OVERVIEW 24 Sept MTL 07/24 AUTHORIZED REPRESENTATIVE (A/R)