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representative is requesting to be removed, a signed statement is not needed by the member. An authorized representative designation is valid on a case until a written and signed request is received for removal. Example 1 Penny is due for renewal of her BadgerCare Plus benefits on August 31. In July, she receives her case summary as part of the administrative renewal process. Penny’s case summary lists her mom, Darlene, as her authorized representative. Penny no longer wants Darlene to be her authorized representative. Penny crosses out the authorized representative information on the case summary, signs it, and mails it to the IM agency. The IM agency receives the case summary on August 3. Based on Penny’s handwritten update on the case summary, the IM agency removes Darlene as Penny’s authorized representative effective on August 3. 34.1.1 Additional Responsibilities The applicant or member can choose to appoint the person who is acting as their authorized representative to receive the member’s ForwardHealth card and is also allowed to do the following tasks: • Enroll the applicant or member in an HMO • Contact Member Services or the HMO about a bill, service or other medical information, including Protected Health Information (PHI) An authorized representative who is appointed by the member to have these additional functions is coded in CARES as a Medicaid (MA) Payee. The authorized representative and the MA Payee must be the same person, and the MA Payee cannot be an organization. If the member’s authorized representative is an organization and the member wants to appoint a MA Payee, the member must change the authorized representative to a person and authorize that person to have the MA Payee functions. The applicant or member can appoint their authorized representative to fulfill the additional responsibilities on Section 1 Part C of the Appoint, Change or Remove Authorized Representative: Person form (F-10126). The applicant or member acknowledges that they are authorizing the disclosure of PHI to the authorized representative since the authorized representative will have access to medical information such as health care services or treatments, medical bills, etc. There is no time limit on the MA Payee designation. An applicant or member can request removal of the MA Payee in writing at any time. For example, the applicant or member can submit the Appoint, Change or Remove Authorized Representative form or write a letter indicating the MA Payee removal. This page last updated in Release Number: 23-04 Release Date: 12/18/2023 Effective Date: 12/18/2023 34.2 Legal Guardians and Conservators Persons or interested parties may petition a court to appoint a guardian or conservator. There are a variety of reasons that an appointment may be sought including but not limited to: • Inability to manage finances • Inability to manage personal health • Inability to function safely without supervision • Parent or guardian of minor is now deceased