Skip to main content

Provider Update: July 5, 2016

CD-PASS Designation of Authorized Representative form update

The CD-PASS service option has updated and retitled the Designation of Guardianship, Power of Attorney, and Designation of Authorized Representative form, version 7/20/09.  The new form is titled the CD-PASS Designation of Authorized Representative form, draft version 6/9/16, and is available with this bulletin, as well as on the Public Partnerships website: .

The purpose of this update is to bring this form into compliance with DHS standards for accessibility and to address long-standing deficiencies within this form.  This form is intended to allow ADvantage Members to appoint a person to assist with CD-PASS services and to identify the level of authority that person has been granted.  This form is required with Service Plan addendums transitioning Members to CD-PASS, and for all CD-PASS Service Plan reassessments.

Key form updates:

  • Definitions of roles are presented on page 1.
  • Sections for Legal Guardian, Power of Attorney, and Authorized Representative have been combined to reduce confusion.
  • Space has been created to define specific activities that the representative will perform.
  • Signature line for Case Manager has been added.

Implementation Timeline:

  • The previous version of this form (version 7/20/09) will be phased out according to the following timeline:
    • 7/5/16 – Updated form (version 6/9/16) released for immediate use.
    • 7/5/16 – 8/31/16 - Informational conditions only will be placed on T1016 service lines (no authorizations will be impacted).
    • 9/1/16 to 9/30/16 – S5125, S5125TF, T2025, and T1016 service lines will be conditionally authorized for 30 days, requiring submission of form version 6/9/16.
    • 10/1/16 - Full implementation of the updated form: All CD-PASS and Case Management service lines will be Not Authorized pending receipt of the Designation of Authorized Representative form, version 6/9/16.

If you have any questions regarding the information provided above, please feel free to contact us via Smarter Mail at:

Back to Top