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. You can also search for this form and other forms by clicking Resources in the top bar, then select Form Library to search the forms. You can search by name, or narrow the search to only forms from Cuyahoga Job and Family Services.
• 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.

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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:

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.

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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.