State Form 55366 (DFR2123HC) Authorized Representative for Health Coverage - Indiana

What Is State Form 55366 (DFR2123HC)?

This is a legal form that was released by the Indiana Family and Social Services Administration - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is State Form 55366?A: State Form 55366 is a form used in Indiana for designating an authorized representative for health coverage.

Q: What is an Authorized Representative?A: An authorized representative is a person who can act on your behalf when dealing with your health coverage.

Q: Why would I need an Authorized Representative?A: You may need an authorized representative if you are unable to handle your health coverage matters on your own due to various reasons, such as illness or disability.

Q: How do I designate an Authorized Representative using State Form 55366?A: To designate an authorized representative, you need to fill out State Form 55366 and provide the relevant information about the authorized representative.

Q: Can I choose any person to be my Authorized Representative?A: Yes, you can choose any person (18 years or older) to be your authorized representative, as long as they are willing and able to act on your behalf.

Q: What are the responsibilities of an Authorized Representative?A: The authorized representative is responsible for helping you with your health coverage matters, such as enrolling in a plan, submitting claims, or making changes to your coverage.

Q: Can I change my Authorized Representative?A: Yes, you can change your authorized representative at any time by notifying your health coverage office and providing them with the new representative's information.

Q: Do I need to renew the designation of my Authorized Representative?A: In Indiana, the designation of an authorized representative expires after one year. You will need to renew the designation by submitting a new State Form 55366.

Q: What if I have questions or need assistance with State Form 55366?A: If you have any questions or need assistance with State Form 55366, you can contact your local health coverage office for guidance and support.