APPOINTMENT OF AGENT
FOR MEDICAID DETERMINATION AND APPEAL PROCESS
Instructions: This form is used by private eligibility service organizations and medical facilities as a
release to act as an Agent for a Medicaid/MIAP applicant/beneficiary through the application, review
and appeal processes. A copy of this form must be maintained in the Medicaid case record. The
Medicaid eligibility worker can work with a representative of the organization indicated on this form as
needed to facilitate the processing of an application/review. This form does not grant Authorized
Representative status to any Agent but provides for release of any and all relevant information
concerning the applicant/beneficiary to the Agent.
Name of Applicant/Beneficiary:
Social Security Number:
I appoint
(must be an individual), operating
as a representative/employee of
(name of company)
to act as my Agent in regards to my application/review for Medicaid/MIAP benefits, and if necessary,
any related appeal. This appointment allows the Agent or designee to inquire about and receive
information about the status of my application, review or appeal. The Agent may also assist in obtaining
information required by the South Carolina Department of Health and Human Services (DHHS) to make
an eligibility decision and DHHS may make requests for specific information to the Agent acting in this
capacity. Unless directly related to information specifically provided by the Agent, DHHS cannot release
details of the case record to any Agent without my express written permission.
Signature of Applicant/Beneficiary:
Date:
ACCEPTANCE OF APPOINTMENT AS AGENT
I agree to act as an Agent for the above named individual during the application, review and/or appeal
process for Medicaid eligibility. In accepting the duties of an Agent, I agree to be jointly and individually
responsible for reporting any known changes in income or resources within 10 days of the change, or
as soon as I become aware of the change, during the application, review and/or appeal. I understand
that, if I deliberately give false information or withhold any information concerning the individual’s
situation, I could be liable for prosecution for fraud and/or perjury. I understand that I will not be held
responsible for changes of which I am not aware. As the individual’s Agent, I understand that it is my
duty to assist in procuring and verifying relevant information. I also understand that if the
applicant/beneficiary withdraws his consent for me to act as an Agent, I must notify the South Carolina
Department of Health and Human Services immediately through completion of the withdrawal section of
this form.
Signature of Agent/Intake Worker:
Telephone Number:
Date:
WITHDRAWAL OF APPOINTMENT OF AGENT
I,
to continue to act as my Agent.
Signature of Applicant/Beneficiary:
DHHS Form 934 (October 2010)
, withdraw my consent for the above named entity
Date:
Instructions
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This form is intended for sponsored workers, private eligibility service organizations and
medical facilities as a release to act as Agent.
This form is not related to the eligibility determination process. The applicant does not
have to sign this form to qualify for coverage and must not be given that impression
however must be given the option to sign.
This is not the assignment of an Authorized Representative. It is an authorization to
release information.
This form remains in effect indefinitely if the application is approved and for 30 days
after a negative action.
The sharing of this information is solely for the purpose of processing an application or
review, or assisting with an appeal and must not be used for any other purpose. “Initial
processing’' means taking applications, assisting applicants in completing the
application or review, providing information and referrals, obtaining required
documentation to complete processing of the application or review, assuring that the
information contained on the application or review form is complete, and conducting any
necessary interviews. It does not include evaluating the information contained on the
application or review and the supporting documentation or making a determination of
eligibility or ineligibility. “Assisting with an appeal” means to work with or on behalf of the
applicant/beneficiary to obtain and/or present information or other supporting
documents in preparation for or during an appeal of a negative or adverse action taken
by DHHS.
The MEDS note screen must be used to document that a DHHS Form 934 has been
signed by the applicant and is on file.
DHHS Form 934 (October 2010)