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You also agree to comply with applicable state and federal laws concerning conflicts of interest. It also allows the plan to assist the consumer with their medicaid application and renewal. Tty users should call 1‐800‐662‐1220 or 1‐877‐662‐4886 for tty in spanish. Find the form, complete it, and return it by fax or mail. Web authorized representative identity verification form. Web learn how to choose an authorized representative to act for you on matters related to new york medicaid choice. Web need help with this form? Web new york medicaid choice 0000000000cf. Web enrolling in a plan is easy and convenient. Web this form allows a consumer to assign, change or discontinue an authorized representative for medicaid and personal health plans. To authorize someone to act as your representative, fill out the form below or provide documents showing that you already have a legally appointed representative. If you need to request a copy of this form, please call 1‐855‐355‐5777. Within the scope of this authorization as if you were the applicant or enrollee.