You can give a trusted friend, relative, partner, or attorney permission to talk with us about your assessment and act for you on matters related to your case. This person is called an “authorized representative.” 

An authorized representative can:

  • Receive copies of notices and other communications;
  • Request appeals; and
  • Act on your behalf in all other matters with New York Medicaid Choice (NYMC) and the New York Independent Assessor Program.

You should complete the Authorized Representative Designation Form if:

  • You want to name someone as your authorized representative for the first time; or
  • You want to change the authorized representative you named at any other time.

If you already have a legal document that authorizes someone to act for you under New York State law, NYMC can accept a copy of that document in place of the Authorized Representative Designation Form. You can mail or fax us as described below.

Examples of documents that we accept for this purpose are a court order establishing guardianship or a power of attorney form.

How do I find the Authorized Representative Designation Form?

  • To receive an Authorized Representative Designation Form and a prepaid return envelope, please call  1-800-505-5678; TTY users: 1-888-329-1541 or
  • You can print the form here. 

How do I complete the form?

  • Complete Sections 1 and 3 and sign the form. Make sure to provide a telephone number where we can reach you.
  • Have your authorized representative complete Section 2 and sign the form.
  • Return the form via fax or mail:

FAX: (917) 228-8601 
MAIL: New York Medicaid Choice, P.O. Box 5009, New York, NY 10274

What happens next?

Once New York Medicaid Choice receives your completed Authorized Representative Designation Form, the information will be added to your record. If there is an issue with your form, a counselor will reach out to you by phone.

How do I remove an Authorized Representative?

You may remove an authorized representative by calling New York Medicaid Choice at 1-800-505-5678; TTY users: 1-888-329-1541. You can call Monday through Friday from 8:30 a.m. – 8:00 p.m. and Saturday from 10:00 a.m. – 6:00 p.m. We are closed on state holidays.

QUESTIONS: If you have any questions, call New York Medicaid Choice and a counselor will be glad to assist you. Our counselors can help you in any language.