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Ohio Department of Job and Family ServicesDESIGNATION OF AUTHORIZED REPRESENTATIVE First Name of Applicant/ Recipient Street Address, including Apt. #Last NameMIMedicaid billing # or SSN. CountyCityZipI
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Step 1: Download the jfs-6723-authorized-representative-form-1 from the official website of the issuing authority.
02
Step 2: Fill in the personal details of the authorized representative including name, address, contact information, and relationship to the individual being represented.
03
Step 3: Provide the details of the individual being represented including name, address, and case number if applicable.
04
Step 4: Sign and date the form to certify that the information provided is accurate.
05
Step 5: Submit the completed form to the appropriate office or agency as specified in the instructions.

Who needs jfs-6723-authorized-representative-form-1?

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Individuals who are unable to represent themselves due to age, disability, or other circumstances may need to have an authorized representative fill out this form on their behalf.
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The jfs-6723-authorized-representative-form-1 is a document used to designate an individual as an authorized representative who can act on behalf of another person or entity in specific administrative matters.
Individuals or entities that wish to have someone act on their behalf in administrative procedures are required to file the jfs-6723-authorized-representative-form-1.
To fill out the jfs-6723-authorized-representative-form-1, gather necessary personal information of both the individual authorizing the representative and the representative themselves, then accurately complete all sections of the form, ensuring to sign and date appropriately.
The purpose of the jfs-6723-authorized-representative-form-1 is to formalize the authorization of a representative to handle specific administrative tasks or communication with authorities on behalf of another individual or entity.
The information required includes the names, contact information, and signatures of both the person granting the authority and the authorized representative, along with any specific instructions or scopes of authority.
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