DHS Authorized Representative Form: How to Fill Out and Submit

A DHS authorized representative form is how you formally name a person or organization to handle your benefits case with your state Department of Human Services. Each state publishes its own version — Wisconsin uses Form F-10126A, New York uses DOH-5247, Ohio uses ODM 06723 — but all of them follow the same federal framework at 42 CFR § 435.923.¹ Fill it out with the applicant’s information, the representative’s information, and both signatures, then submit it to your local DHS office.

Who You Can Name as Representative

Federal rules require every state Medicaid agency to let you pick an individual or an organization to act on your behalf for applications, renewals, and ongoing communications with the agency.¹ The regulation sets no minimum age and lists no required credentials. Most people name a family member, a close friend, a social worker, or an attorney. Community health centers and legal aid offices can also serve.

Holding power of attorney or legal guardianship does not by itself make you an authorized representative. You still need to submit proof of that legal authority — a copy of the court order or POA document — with the form, and that documentation takes the place of the applicant’s own signature.²³ If the applicant already has a representative and you hold guardianship, you are the one who appoints or changes it.

One boundary worth naming up front: this form does not give anyone authority to receive or spend the applicant’s Social Security or SSI payments. The Social Security Administration treats that as a separate role called representative payee, and it requires its own application through SSA.⁴ The same person can hold both roles, but each needs its own designation.

What to Gather Before You Start

Missing information is the most common reason agencies bounce the form back. Have these on hand before you sit down with it:

The applicant’s full legal name, date of birth, mailing address, and phone number.
The case or client ID number, if benefits are already active. Check any prior letter from the agency.
The representative’s full legal name, address, and phone number, plus their job title and organization if they work for one.
A decision about scope. Some state forms let you limit what the representative can do — for example, letting them report changes but not sign a new application. Know what you want to grant before you check the boxes.
Identity documents where the state requires them. New York, for instance, asks the representative for a government photo ID such as a passport, driver’s license, or military card, or two secondary documents like a birth certificate and Social Security card.

Social Security numbers may be requested but are not always mandatory; read your state’s instructions. What is universal: both the applicant (or their legal guardian) and the representative must sign and date the form for the designation to take effect.⁵

Filling Out the Form Section by Section

Applicant Section

Enter your full legal name exactly as it appears on your benefit case. Add your case or client ID number if you have one. Many forms also ask for your date of birth and the specific programs you receive — Medicaid, SNAP, TANF, and so on. If you are completing the form for someone under your legal guardianship, sign here on their behalf and attach the court order.

Representative Section

The representative enters their own name, contact information, and relationship to the applicant. Employees of an organization should include their title and the organization’s name. By signing, the representative agrees to keep information about the applicant confidential and to carry out the same responsibilities the applicant would have.¹

Authorization Scope

Some states give one blanket authorization. Others let you tick boxes to limit what the representative can do — receiving copies of notices, say, without the ability to sign renewals. Federal rules allow agencies to track those partial permissions.³ Read the checkboxes carefully before signing; the language on the form controls what powers actually transfer.

Signatures and Dates

Both parties sign and date the form. Signatures are handwritten unless you are filing through a state online portal that supports electronic signing. Federal regulations require agencies to accept electronic signatures, including telephonically recorded ones, along with handwritten signatures sent by fax or other electronic means.¹ Notarization is generally not required, though a small number of states may request it in specific circumstances.

How to Submit It

Federal rules require the agency to accept the designation through any channel it accepts applications through, so if your state takes applications online, by mail, by fax, by phone, and in person, the authorized representative form goes through those same channels.¹ In practice that means:

In person at your local DHS or county assistance office.
By mail to the address on the form or your state agency’s website.
By fax to the number the office lists for document intake.
Through the state’s online benefits portal. Wisconsin’s ACCESS, for example, lets you designate a representative inside the system with an electronic signature.

Keep a copy of the signed form for your own records no matter which route you use. Processing times are not set at the federal level and vary by state and caseload. If a renewal deadline is close, filing in person and flagging the urgency for the caseworker is the fastest path.

What the Representative Can Do Once Approved

Once the agency processes the form, your representative steps into your place for dealings with the agency. Federal regulations authorize them to sign a new application, complete renewals, receive agency notices about eligibility and hearings, report household changes, respond to requests for information, and attend hearings on your behalf.¹ Whether you continue to receive notices alongside the representative depends on the state.

The representative is held to the same standards you would be. If a change in income or address must be reported within a set number of days, that deadline applies to them too. Missed or inaccurate reporting can cut or end benefits, and responsibility for the lapse falls on the representative as well as the applicant.

Changing or Revoking the Designation

You can end the arrangement any time by notifying the agency in writing that the representative is no longer authorized to act for you. The representative can also step down on their own by notifying the agency. In either case, the notice needs the signature of whoever is ending it.¹ Many states put appointment, change, and removal on the same form — Wisconsin’s F-10126A does all three.

If the legal basis for the representation ends, for instance when a court rescinds a guardianship, the designation ends automatically once you tell the agency. To switch to a new representative, submit a new form naming the replacement. You do not need to revoke the old one first; the new designation supersedes it.

1
eCFR. 42 CFR 435.923 – Authorized Representatives
2
Wisconsin Department of Health Services. ForwardHealth: Having Someone Help You with Eligibility or Benefits
3
eCFR. 45 CFR 155.227 – Authorized Representatives
4
Social Security Administration. Frequently Asked Questions for Representative Payees
5
Ohio Department of Medicaid. Designation of Authorized Representative