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Personal Representative Designation

As the head of your case, you can choose other people who we can talk to and share information with about your Medicaid benefits and managed care enrollment. These people are called Personal Representatives. There are three ways you can add them to your case:
 

  1. Phone: Call us at 1-877-912-8880 (TTY: 1-866-565-8576). Call Monday to Friday, 8 a.m. to 6 p.m. The call is free.
  2. Online: Fill out and submit the digital Personal Representative Designation form. To submit the form online, all you need is an email address.
  3. Fax: Download, print, and fill out the Personal Representative Designation form. Fax the completed form to 1-312-596-0249.

How to fill out the Personal Representative Designation form

If your Power of Attorney (POA) or guardian signs your Personal Representative Designation form for you, they must also submit their POA or Guardianship papers.