• 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
  • An Authorized Representative may (please check all that apply):
  • HIDE- An Authorized Representative may (Circle all that apply)

  •  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
  • Format: (000) 000-0000.
  • Is there an Authorized Representative?*

  • I the participant hereby assign the person stated below as my Authorized Representative in the ComCare Program:

  • Format: (000) 000-0000.

  • 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/
  • Date of Signature*
     - -

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

  • Date of Signature*
     - -
  • Should be Empty: