Ohio ER Assignment of Consumer Authorized Representative

Ohio Employer Assignment of Consumer Authorized Representative

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
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Ohio Assignment of Consumer Authorized Representative

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
Assignment of Consumer Authorized Representative

An Authorized Representative can be a Consumer’s legal guardian, family member or any other person identified by the Consumer/Employer in consultation with the staff to manage Consumer/Employer duties when the Consumer/Employer is unable to do so independently.

An Authorized Representative must:
1. Show a strong personal commitment to the Consumer/Employer
2. Show knowledge about the Consumer/Employer's preferences
3. Agree to visit the Consumer/Employer at least every pay period
4. Be willing and able to meet all program requirements for the Program
5. Be at least 18 years old
6. Be willing to submit to criminal background checks, if requested
Sign/complete program related forms and paperwork including verifying provider/employee time submittalsObtain confidential information from Morning Sun regarding the Consumer/Employer's service authorization, provider payroll, etc.Perform employer related duties, such as but not limited to: assist in hiring and terminating provider staff, managing the Consumer/Employer's provider staff, completing forms, and managing the monthly service authorization
Sign/complete program related forms and paperwork including verifying provider/employee time submittalsObtain confidential information from Morning Sun regarding the Consumer/Employer's service authorization, provider payroll, etc.Perform employer related duties, such as but not limited to: assist in hiring and terminating provider staff, managing the Consumer/Employer's provider staff, completing forms, and managing the monthly service authorization
An Authorized Representative Cannot:
1. Be paid for this service or be hired by the Consumer/Employer as a provider/employee
2. Be known to conduct illegal activites
3. Have any history or physical, mental or financial abuse
Participant Legal Name*

Legal First NameLegal Last Name
Participant Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Participant Address*

Street Address

Apartment or Unit number

CityState

Zip Code
YesNo
I the participant hereby assign the person stated below as my Authorized Representative in the ComCare Program:
Legal Name of Authorized Representative*

First NameLast Name
Authorized Representative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Representative Email*
example@example.com
Authorized Representative Address

Street Address

Street Address Line 2

CityState

Zip Code
Authorized Representative Relationship to Consumer
Authorized Representative: Please initial to indicate your understanding below:
After reading the description that outlines the responsibilities of the Authorized Representative, I understand my functions and I am willing to volunteer to serve as the Participant/Employer's Authorized Representative without payment.*
I understand that I cannot be paid in this role and cannot become a paid caregiver or provider.*
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Employer Legal Name*

Legal First NameLegal Last Name
Employer Email*
example@example.com
Employer Signature*

Clear
Date of Signature*

MonthDayYear
Date
I hereby agree to serve as the Authorized Representative fo the above named Participant and understand my responsibilities and duties under the ComCare Program.
Authorized Representative Name*

Legal First NameLegal Last Name
Authorized Representative Signature*

Clear
Date of Signature*

MonthDayYear
Date
Should be Empty:

Ohio Employer Assignment of Consumer Authorized Representative

Ohio Assignment of Consumer Authorized Representative

Signatures