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Account information authorization Member Information Name: ___ Medicaid number: ___ Email Address: ___ Phone number(s): Home: ___ Cell: ___ The following individuals have the members permission to

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Prepare all necessary documentation such as identification, medical records, and financial information.

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Elderly individuals who require assistance with daily tasks such as medication management, personal care, and meal preparation.

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Persons with disabilities who may need support with mobility, communication, or other specific needs.

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What is elderly and persons with?

Elderly and persons with disabilities are individuals who may require additional assistance or accommodations due to their age or physical/mental condition.

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Caregivers or family members of elderly and persons with disabilities are generally required to file for them.

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