How To Designate an Authorized Representative

To designate an authorized representative for SNAP, Medicaid or cash assistance, you can use our CJFS Designation of Authorized Representative Form. You can access the form from the link online and in person:

Online
Download or print out the CJFS Designation of Authorized Representative Form.
In person
You can pick up forms from all our listed drop-box locations below, with the exception of Old Brooklyn Neighborhood Family Service Center, which is a drop-off only site.

To submit your Designation of Authorized Representative Form

There are a few options for submitting this form to Cuyahoga Job and Family Services:

Email: JFS-Cuyahoga-MIPC@jfs.ohio.gov
Fax: 216-987-7700
Mail: 1641 Payne Ave., Cleveland, OH 44114

In-person Drop box locations:

Virgil E. Brown
1641 Payne Ave.
Cleveland, OH 44114

Westshore
9830 Lorain Ave.
Cleveland, OH 44102

Quincy Place
8111 Quincy Ave.
Cleveland, OH 44104

Jane Edna Hunter
3955 Euclid Ave.
Cleveland, OH 44115

Mt. Pleasant
13815 Kinsman Rd.
Cleveland, OH 44120

Other Things to Know

Customers may use the “CJFS Designation of Authorized Representative” Form to designate someone to represent you. On this form you can select which programs you would like them to represent you and the duties you authorize them to perform on your behalf.
You are not required to use the “CJFS Designation of Authorized Representative” Form, however any designation you submit must meet the state guidelines outlined below.
There are spaces to designate an authorized representative on Medicaid benefit applications and reapplications, but these do not meet the current Medicaid requirements, unless an additional appendices or attachments are completed:
- To designate an authorized representative on Form 7216 “Application for Health Coverage and Hep Paying Costs” you must complete Appendix C.
- To designate an authorized representative on the Medicaid Renewal Form, you must complete Attachment A.

State Guidelines for Designating an Authorized Representative

As of April 7, 2021, the Ohio Department of Medicaid (ODM) requires customers who want to designate an authorized representative for Medicaid benefits must include:

Signature of the person applying for benefits
Signature of the authorized representative
List of duties the authorized representative can perform
Agreement that the authorized representative will maintain the individual’s confidentiality.
Agreement that he authorized representative will adhere to regulations and laws concerning conflicts of interest and confidentiality of information, if the authorized representative is an organization.