Indiana
Authorized representative for health coverage form
No One Left Outside provides source-based information. The issuing agency or plan decides eligibility, acceptance and availability.
Source / last checked DFR: Forms - 2026-11-02
- Form number
- 55366
Authorized representative for health coverage form - Reviewed 2026-11-02
- What it is for
- Authorized representative for health coverage form
DFR: Forms - Reviewed 2026-11-02
- Issuing agency
- Indiana Family and Social Services Administration (FSSA); this form appears in the DFR forms catalog.
DFR: Forms - Reviewed 2026-11-02
- Program
- health coverage
DFR: Forms - Reviewed 2026-11-02
- Jurisdiction
- Indiana
DFR: Forms - Reviewed 2026-11-02
- Category
- HEALTH COVERAGE
Authorized representative for health coverage form - Reviewed 2026-11-02
- Form type
- form
DFR: Forms - Reviewed 2026-11-02
- Who fills it out
- If you want someone to act on your behalf in applying for benefits and/or act for you on an ongoing basis, this form must be completed. Be sure to select the function(s) that the representative is being authorized to do. You can select more th an one representative and choose the same or different functions. The representative may be an individual or an organization. Complete ONE form per authorized representative. Both you and your representative must sign and date this form.
Authorized representative for health coverage form - Reviewed 2026-11-02
- How to submit
- General DFR forms-catalog route: fax 888-436-9199, or deliver or mail to your local county office. Follow document-specific instructions where supplied.
DFR: Forms - Reviewed 2026-11-02
- Documents to include
- (If applicant/recipient is medically incapable to sign authorization, provide medical documentation.)
Authorized representative for health coverage form - Reviewed 2026-11-02
- Languages
- English
Authorized representative for health coverage form - Reviewed 2026-11-02
- Official page
- https://www.in.gov/fssa/dfr/forms-documents-and-tools/forms
DFR: Forms - Reviewed 2026-11-02
- Direct form link
- https://forms.in.gov/Download.aspx?id=11310
DFR: Forms - Reviewed 2026-11-02
- Revision date
- R2 / 12-14
Authorized representative for health coverage form - Reviewed 2026-11-02
- Signature
- Both you and your representative must sign and date this form.
Authorized representative for health coverage form - Reviewed 2026-11-02
- Accessibility
- Not listed yet. Call to confirm.
- What the form says
I understand that I am responsible for the information anyone acting as my authorized representative gives, including any information that may be incorrect. I also understand that if at any time I wish to stop the person(s) I chose from being my authorized representative, it is my responsibility to contact the Division of Family Resources.
Authorized representative for health coverage form - Reviewed 2026-11-02
Check the form number and revision before using it. Read the agency's privacy and consent terms before sharing personal information.