Form DOH-5247 Medicaid Authorized Representative Designation / Change Request - New York

Form DOH-5247 Medicaid Authorized Representative Designation / Change Request - New York

What Is Form DOH-5247?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form DOH-5247?
A: Form DOH-5247 is the Medicaid Authorized Representative Designation/Change Request form used in New York.

Q: What is the purpose of Form DOH-5247?
A: The purpose of Form DOH-5247 is to designate or change the authorized representative for Medicaid beneficiaries in New York.

Q: Who can use Form DOH-5247?
A: Medicaid beneficiaries in New York can use Form DOH-5247 to designate or change their authorized representative.

Q: How do I fill out Form DOH-5247?
A: To fill out Form DOH-5247, provide the required information about the Medicaid beneficiary, the authorized representative, and their relationship or authority to act on behalf of the beneficiary.

Q: How do I submit Form DOH-5247?
A: You can submit Form DOH-5247 by mail, fax, or in person at your local Medicaid office in New York.

Q: What is the deadline for submitting Form DOH-5247?
A: There is no specific deadline for submitting Form DOH-5247. However, it is recommended to submit it as soon as possible to ensure timely processing.

Q: Can I designate more than one authorized representative on Form DOH-5247?
A: Yes, you can designate multiple authorized representatives on Form DOH-5247 by providing their information in the designated section of the form.

Q: Can I change my authorized representative at any time?
A: Yes, you can change your authorized representative at any time by submitting a new Form DOH-5247 with the updated information.

Q: Is there a fee for submitting Form DOH-5247?
A: No, there is no fee for submitting Form DOH-5247.

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Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the New York State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOH-5247 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

Download Form DOH-5247 Medicaid Authorized Representative Designation / Change Request - New York

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  • Form DOH-5247 Medicaid Authorized Representative Designation / Change Request - New York, Page 1
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