Form H1003
04-2015-E
Appointment of an Authorized Representative
to Allow Another Person to Act for You
If you want, you can give someone the right to act for you (an authorized representative).
That person can:
•Give and get facts for this application.
•Take any action needed for the application process. This includes appealing an HHSC decision.
•Take any action needed to enroll in Medicaid or CHIP. This includes picking a health plan.
•Take any action needed to get benefits. This includes reporting changes and renewing benefits.
You can have only one authorized representative for all your benefits from HHSC. If you want to change your authorized representative: (1) log in to your account on www.YourTexasBenefits.com and report a change, or (2) call 2-1-1 (after you pick a language, press 2). If you’re a legally appointed representative for someone on this application, send proof with this form.
1. Contact Information
Client or Applicant Name |
Case Number |
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Name of person who can act for you (authorized representative) |
Organization |
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Address of person who can act for you (authorized representative) |
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Telephone number with area code of person who can act for you (authorized representative) |
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2. The authorized representative is your:
Power of attorney
Court-appointed guardian (give end date):
Other (tell us about your relationship):
3.Sign below if you want the person you are listing on this form to be your authorized representative.
I certify under penalty of perjury that the information I have provided on this application is true and complete to the best of my knowledge. If it is not, I may be subject to criminal prosecution.
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Signature — Person who agrees to be the authorized representative |
Date |
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(This person must be age 18 or older.) |
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Signature — Client or Applicant |
Date |
