Consent for Authorized Representative

If you would like, you can give someone the right to act for you. This person can give and get facts for this application, take any action needed to enroll in benefits, and take any action needed to get benefits.

Please choose the program(s) for which you would like an authorized representative: (Medical Assistance ) (Food Assistance (Cash Assistance) This person can apply for benefits, provide interview assistance, get notices, report changes, and make inquiries. If the SNAP interview process is completed by the Authorized Representative, they must provide a form of identification. Your household will be held liable for any overissuance that results from the representative providing incorrect information. (Note: Eaton Agency only represents clients regarding their Healthcare. You will need to work with DHS to secure and retain SNAP benefits etc.)

By signing, I certify that the individual(s) designated above is (are) allowed to act on my behalf. I understand my household will be held liable for any overissuance that results from the authorized representative providing incorrect information. I understand that anyone knowingly providing false information may be prosecuted under applicable federal and state statutes. I understand that the power to act as an authorized representative is valid until I modify the authorization or notify the agency that the representative is no longer authorized to act on my behalf, or the authorized representative informs the agency that they are no longer acting in such capacity, or there is a change in the legal authority upon which the individual or organization's authority was based.

I agree to maintain, or be legally bound to maintain, the confidentiality of any information provided by the agency regarding the client. If the authorized representative for Health Care is a provider, staff member, or volunteer of an organization, I affirm that I will adhere to the regulations in 45 CFR part 431, subpart F and at 45 CFR $155.260(f), 45 CFR $447.10, as well as other relevant State and Federal laws concerning conflicts of interest and confidentiality of information.