1619 NW 136th Ave

Suite D100
Sunrise, FL 33323

Name: WALTER G SMITH JR

E-mail/Fax: smith2685@yahoo.com

UnitedHealthcare® appreciates this chance to help make your health care easier. Thank you for working
with us to complete the paperwork required to connect you to those programs. Please complete
the enclosed form(s) at your earliest convenience and return to us. Also, please provide copies of any
requested documents.

We will be able to help you with any questions you may have throughout the application process. If you
have any questions please contact us at: 1-855-537-2535 (TTY: 711), Monday – Saturday, 8 a.m. – 8
p.m. local time.

To ensure these documents are routed correctly,

please return this page with your documents.
Thank you.

CONFIDENTIALITY NOTICE:
This package, including any and all accompanying documents (the “Package”) is PRIVILEGED
AND CONFIDENTIAL and is for the named intended recipient only. If you are not the named intended
recipient, access of the Package by you is unauthorized. No confidentiality or privilege is waived or lost by
UnitedHealthcare erroneous distribution. If you are not the named intended recipient and you received the
Package in error, you are hereby notified that any forwarding, disclosure, copying, distribution or use of any
of the information contained in the Package is STRICTLY PROHIBITED. If you have questions about this
program, and would like to speak to an advocate, please call 1-866-427-1873 (TTY: 711). If you have received
this Package in error, please contact our Compliance Department immediately at 1-866-427-1873 (TTY: 711).

1619 NW 136th Ave, Suite D100 • Sunrise, FL 33323

1-855-537-2535 (TTY: 711)
We've assigned a dedicated Benefits Advocate to assist you with your application. This
person will be able to help you with any questions that you might have throughout the
process.

Your assigned Benefits Advocate

Name: Karen G

Phone: (855) 537-2535 (TTY: 711), Ext. 150109

Email: Karen.Garcia@benelynk.com

Fax: 888-236-8699

Benefits Advocate Department Hours:

8:00 AM to 8:00 PM Monday - Friday

For other information regarding your health plan enrollment, feel free to contact the
UnitedHealthcare® main customer service line located on your Member ID card.
-2004870190

AUTHORIZATION OF ASSISTANCE

I, WALTER G SMITH JR
hereby designate BeneLynk* as my Authorized Representative, to:

• Represent me and act on my behalf before the State Medicaid agency for the purpose of
securing and maintaining coverage through the Medicaid/Medicare Savings Programs;
• Assist with completing and submitting application or renewal forms for the programs or
services requested on my behalf, and for online application(s), submit my application online
and electronically sign the application on my behalf;
• Obtain verifications from any third party (e.g. bank or credit union, life insurance company,
• employer, etc.) as needed to complete my application for assistance;
• Receive copies of verification requests and decision notices related to my application from
the State/County Medicaid agency;
• Discuss the status of my application and eligibility with Medicaid agency staff or program
representatives; and
• File an appeal on my behalf and represent me at a fair hearing, if related to securing and/or
maintaining coverage through the Medicaid/Medicare Savings Programs;

If I have a health insurance broker, signing this form does not change my broker. This is
an assistance form and not related to my health insurance selection. BeneLynk provides
information about the renewal process, including options for renewal.

By signing and returning this entire document, I request that Medicaid agencies send copies of all
verification requests and decision notices related to my application to:

BeneLynk
1619 NW 136th Ave
Suite D100
Sunrise, FL 33323

By signing and returning this entire document, I certify that the information I have provided for my
application is true and correct to the best of my knowledge, and understand that neither
UnitedHealthcare® nor BeneLynk is responsible for the accuracy of information that I provided to
complete applications for Medicaid/Medicare Savings Programs or other public assistance
programs. I agree to hold UnitedHealthcare and BeneLynk harmless from any claims, liability,
judgments, damages, or costs that are incurred because of any inaccurate information provided to
UnitedHealthcare and/or BeneLynk.

My participation in this process is voluntary and I am not obligated to provide any information.
There is no cost to me to apply for these programs or for UnitedHealthcare or BeneLynk’s services
and my health plan coverage will not be affected. Any information I provide to UnitedHealthcare or
BeneLynk will be kept private and will not be shared with anyone outside of this process.
UnitedHealthcare and BeneLynk will only use the information to help me secure or maintain the
coverage I have requested, and agree to protect and maintain the confidentiality of any information
-2004870190

received.

While UnitedHealthcare and BeneLynk will assist with my application, I understand that only the
Medicaid agency can approve my application for coverage.

This authorization shall remain in effect until revoked or until I am no longer enrolled in a
UnitedHealthcare plan or until UnitedHealthcare is no longer contracted with BeneLynk. I
understand that I can cancel this authorization at any time by:

1-866-427-1873 (TTY: 711)

Phone: 1-855-915-5252
Email: info@benelynk.com

As this member’s authorized representative, BeneLynk affirms that employees will adhere to the
regulations in Title 42, subpart F, part 431 of the Code of Federal Regulations (CFR) and 45 CFR
155.260(f). Employees will also adhere to all other relevant State and Federal laws concerning con-
flicts of interest and confidentiality of information.

Please feel free to make a copy for your records then sign and return this original document. If
you would like us to provide a copy for you, please contact us.

Member Name: WALTER G SMITH JR

SIGN HERE
_______________________________________________________ _____________________
Member Signature Date

Advocate Name: BeneLynk

Sharrieffa Jones
for BeneLynk
_______________________________________________________ 9/27/2024
_____________________
Advocate Signature Date
* UnitedHealthcare uses BeneLynk to assist enrollees with the enrollment/application process and
follow-up with State Medicaid offices regarding Medicaid/Medicare Savings program applications.

UnitedHealthcare is a Medicare Advantage organization with a Medicare contract. Enrollment in a

UnitedHealthcare plan depends on contract renewal.

This information is available for free in other languages. Please call our Customer Care at the num-
ber on the back of your UnitedHealthcare enrollee ID Card.
 ATTACHMENT C GEORGIA DEPARTMENT OFHUMAN SERVICES
Division of Family and Children Services
Form Approved
OMB No. 0938-1191

Assistance with Completing this Application

SIGNATURE PAGE
You can choose an authorized representative.
You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related
to this application, including getting information about your application and signing your application on your behalf.
This person is called an “authorized representative.” If you ever need to change your authorized representative, contact Division of
Family and Children Services (DFCS) at 1-877-423-4746. If you’re a legally appointed representative for someone on this application,
submit proof with the application.

1. Name of authorized representative (First name, Middle name, Last name)

BeneLynk
2. Address 3. Apartment or suite number
1619 NW 136th Ave D100
4. City 5. State 6. ZIP code
Sunrise FL 33323
7. Phone number 7b. Email
( ) –
1-833-428-2066 governmentrelations@benelynk.com
8. Organization name 9. ID number (if applicable)
BeneLynk
By signing, you allow this person to sign your application, get official information about this application, and act for you on all future
matters with this agency.
10. Your signature 11. Date (mm/dd/yyyy)
SIGN HERE

For certified application counselors, navigators, agents, and brokers only.

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for
somebody else.
1. Application start date (mm/dd/yyyy)

2. First name, Middle name, Last name, & Suffix

3. Organization name 4. ID number (if applicable)

NEED HELP WITH YOUR APPLICATION? Visit JDWHZD\.ga.gov or call us at 1-877-423-4746. Para obtener una copia de este formulario en
Español, llame 1-877-423-4746. If you need help in a language other than English, call 1-877-423-4746 and tell the customer service representative
the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-255-0135.
Form 94a Appendix C (/1)
-2004870190
 State Program Application
Document Checklist
We appreciate the chance to link you with programs to help you. Your state requires proof of
information you provided. They need copies of the papers listed on these pages. If you need
help getting any of these papers, give us a call at (855) 537-2535 (TTY: 711).

Proof of financial assets

Please send a copy of your last three (3) statements for all accounts that you (and/or your
spouse) have:

● Checking account
Note: JOINT CHECKING ACCOUNT FOR WALTER SMITH AND SANDRA ROGERS

Proof of identification and health coverage

Please send a copy of each of the following:

● Medicare card
● Health plan ID card (both sides)
● Picture identification (state ID, driver’s license or United States passport)
● Social Security card

Proof of Income

Please send a proof of all income that you (and/or your spouse) have:

● Social Security Income – you can use a copy of your Award Letter or other proof from the
Social Security Administration (SSA) that shows the amount you get before deductions. If
you need to get proof of your Social Security Income, call the SSA at 1-800-772-1213.
Note: FOR BOTH WALER SMITH AND SANDRA ROGERS

Gather as many of these documents as possible to complete the application process.Then

please send a copy of them to us using the postage-paid envelope included.

If you need any help or have any other questions, please contact me at (855) 537-2535 (TTY:
711), Monday–Saturday, 8AM – 8PM.
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