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To change an authorized representative, the member must complete and submit the Appoint, Change, or Remove an Authorized Representative form (Person F-10126A or Organization F-10126B) to their IM agency. To remove an authorized representative, the member needs to let the agency know of the removal in writing. For example, by completing Section One of the Appoint, Change, or Remove an Authorized Representative form or submitting a signed letter indicating the removal. The member does not need to gather additional signatures from the authorized representative or a witness to complete the removal of an authorized representative. Authorized representatives can also request in writing (for example, a signed statement) to be removed if they no longer want to act as the authorized representative. If an authorized 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 Medicaid 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. 22.5.2 Additional Responsibilities The applicant or member can choose to appoint the person who is acting as his or her 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 will need to 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 listed on Section 1 Part C of the Appoint, Change, or Remove an Authorized Representative: Person form (F-10126A). 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.