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33.2.4 Authorized Representative An authorized representative may act on behalf of the SeniorCare member at application and/or renewals and is authorized to provide information and any documentation that is necessary to establish SeniorCare eligibility. A SeniorCare applicant or member may appoint an individual or an organization as an authorized representative by completing the Appoint, Change or Remove an Authorized Representative: Person form (F-10126A) or Appoint, Change, or Remove an Authorized Representative: Organization form (F- 10126B). There can be only one authorized representative at a time on a case. There is no time limit on how long a person or organization can act as authorized representative. The appointment of the authorized representative is valid until the applicant or member notifies the agency of a change or removal in writing. Once appointed, the authorized representative has the ability to act for all open programs on the case. Organizations acting as authorized representatives must provide the name and contact information of a person from the organization. Once the organization has been appointed as the authorized representative, anyone from the organization will be able to take action on behalf of the applicant or member (not just the person who signed the form on behalf of the organization). If an organization is only changing the contact person for the organization, the member is not required to complete a new Appoint, Change or Remove an Authorized Representative form if the organization is going to remain as the authorized representative. The authorized representative should be familiar with the applicant or member’s household situation and is expected to fulfill their responsibilities to the same extent as the individual being represented. An authorized representative is limited to doing any or all of the following on behalf of the applicant or member: • Apply for or renew benefits • Report changes in the applicant or member’s circumstances or demographic information • Receive copies of the applicant or member’s notices and other communications • Work with the SeniorCare program and IM agency on any benefit-related matters • File grievances or appeals regarding the applicant or member’s eligibility To change or remove an authorized representative, the member must complete and submit the Appoint, Change or Remove an Authorized Representative (Person F-10126A or Organization F-10126B) form.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.