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sample
"rep" letter
For use with a
Medicaid Fair Hearing request
This is a
letter for signature by the person with a disability, appointing
a friend or family member to serve as his or her representative.
Nick Curtis
123 Main St.
Anytown, MI 48000
July 3, 2000
Administrative Tribunal
Michigan Department of Community Health
P.O. Box 30195
Lansing, MI 48909
APPOINTMENT OF REPRESENTATIVE
I want my neighbor, Frances Friendly, to represent me, so that I can live
independently.
_____________________________________
Nick Curtis
[NOTE: If Nick can't sign his
name, let him put his thumb print on the signature line]
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