The person the applicant lists on the 139REP form is called an Authorized Representative. This form gives a trusted person permission to:
- Talk about your application with us, and
- see your information, and
- act for you on matters related to your application.
The applicant, spouse or the applicant’s financial power of attorney or legal guardian must sign the 139REP form to designate someone as an authorized representative. If the 139REP form is not signed by the appropriate person, the authorized person is not valid and DVHA LTC will not be able to discuss the applicant’s case with them.
If the authorized person is the applicant’s legally appointed representative such as a financial power of attorney or legal guardian, the 139REP form is not needed. However, the financial power of attorney or legal guardian document must be on file with Medicaid.