North Carolina Authorized Representative Form for Medicaid

Why You Need Appendix C

If you're an adult child helping a parent apply for North Carolina's Medicare Savings Programs, county DSS caseworkers cannot discuss the case with you, release information to you, or accept instructions from you unless you're formally designated as an authorized representative. Privacy rules apply regardless of family relationship.

The form that establishes this authority is Appendix C (DHB-5202C-ia) — the official NCDHHS Authorized Representative designation.

What Appendix C Lets You Do

Once your parent signs Appendix C and the county processes it, you can:

• Submit the MSP application (DHB-5200-ia and Appendix D) on their behalf
• Receive all official notices from the county DSS — approval letters, denial notices, renewal packets, and termination warnings
• Review your parent's confidential case records
• Communicate directly with the assigned caseworker about eligibility, documentation, and deadlines
• File appeals and represent your parent at local informal hearings

This is particularly valuable when you're helping a parent remotely from another city or state. Without Appendix C, every communication has to go through the applicant, and missed notices — especially renewal deadlines — can result in benefit termination.

What Appendix C Does Not Cover

Appendix C authority is strictly limited to NC Medicaid/DHHS proceedings. It does not:

• Give you authority at the Social Security Administration (SSA requires its own Form SSA-1696 for representative designation)
• Replace a general or durable power of attorney
• Grant access to financial institutions
• Make you a Representative Payee for Social Security benefits

If your parent needs help with SSA matters — like filing for Extra Help or coordinating a conditional Part A enrollment — you'll need to file SSA-1696 separately at the local Social Security office.

How to File

Paper: Download DHB-5202C-ia from medicaid.ncdhhs.gov. Your parent signs it, designating you by name. Submit the signed form with the MSP application (or separately if the application was already filed) to the county DSS office by mail, fax, or in person.

Online through ePASS: The ePASS portal has an authorized representative section within the application workflow. Complete it during the initial application filing.

Either way, the designation takes effect once the county processes it. If you mail it, call the county DSS to confirm receipt and processing — ePASS won't show this status reliably.

Important: Don't Share Login Credentials

A common shortcut that creates real problems: logging into ePASS under your parent's NCID and submitting the application as if you were them. This violates the portal's terms of use and can create identity verification issues that delay processing.

Use Appendix C instead. It's the official route, and it gives you formal standing that matters if anything goes wrong — including the right to file an appeal if the application is denied.

Renewals and Ongoing Representation

Appendix C designation remains active until your parent revokes it or the county closes the case. You'll receive the annual renewal packet and any interim notices at the address you listed on the form. This is one of the biggest practical benefits — if a renewal packet isn't returned within 30 days, the county sends a termination notice with an effective date, and having the notices sent to someone who will act on them helps prevent a lapse.

The North Carolina Medicare Savings Programs & Extra Help Guide includes the full authorized representative walkthrough, including how to coordinate Appendix C with SSA-1696 when your parent needs help with both state and federal filings.

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