Appendix C (OMB No. 0938-1191)

Medicaid Agency

This government document is issued by Medicaid Agency for use in Alabama

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File Details: PDF (265 KB)
Downloads: 18
Source
https://medicaid.alabama.gov/documents/9.0_Resources/9.4_Forms_Library/9.4.1_Applicant-Recipient_Forms/9.4.1_AppxC_Joint_8-28-13.pdf

To be used if the applicant wishes to give a trusted person permission to help with the application (also known as an authorized representative).

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