Provider Notice Issued 11/02/2018

Date:  November 2, 2018
To:  Providers of Long Term Care
Re:  Approved and Authorized Representative Forms _____________________________________________________________________________________
This Notice informs providers that, effectivewith the date of this notice, two forms must be completed and submitted to the Department of Human Services (DHS) prior to acting on behalf of a resident as a legal representative for a Medicaid application or appealling of a denial of coverage. 
DHS form, IL 444-2998, Approved Representative Form, must be completed and signed by both the applicant and  and Approved Representative and submitted to DHS to allow a provider to act as representative of a resident to apply for benefits and receive copies of the applicant’s notices.  Approved Representatives can be designated within ABE as part of the application, or added in Manage My Case.  In both instances, the signed form should also be uploaded into Application for Benefit Eligibility (ABE) or mailed to the address included on the form.
DHS form, IL 444-0960, Authorized Representative Form for Appeals, must be completed and submitted to DHS to allow a provider to act as representative of a resident to appeal a denial of coverage.  Authorized Representatives for appeals will only receive information relative to the appeal.
Directions on how to complete and submit representative forms to DHS are included on each form.  Providers should retain copies of any completed approved representative forms they have submitted to DHS.
Questions regarding this notice may be directed to the Bureau of Long Term Care at
Teresa T. Hursey
Medicaid Administrator



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