How To Submit an Authorized Representative Verification Form - Updated 03/20/2009
- What is an Authorized Representative Verification Form?
- Who may complete an Authorized Representative Verification Form?
- Do I have to submit an Authorized Representative Verification Form per Plan Sponsor ID or for each Application ID?
- When should I submit an Authorized Representative Verification Form?
- Do all sections of the Authorized Representative Verification Form have to be completed?
- How do I complete an Authorized Representative Verification Form?
- If my organization re-assigns the Authorized Representative role, do I have to submit a new Authorized Representative Verification Form?
- Where do I send the Authorized Representative Verification Form?
- How do I know my Authorized Representative Verification Form has been approved?
What is an Authorized Representative Verification Form?
The Authorized Representative Verification Form is written documentation from the Plan Sponsor verifying that the Authorized Representative listed on the RDS Application is authorized to act on the Plan Sponsor's behalf.
For more information about the Authorized Representative, go to: RDS Secure Web Site User Roles section of Chapter 3 in the RDS User Guide.
Who may complete an Authorized Representative Verification Form?
The Authorized Representative Verification Form must be completed by the Authorized Representative Verifier. The Authorized Representative Verifier who completes and signs this form must be an employee of the Plan Sponsor. For multi-employer plans, the Authorized Representative Verifier may be an employee, or a member of the jointly appointed board of trustees, which includes both labor and management.
The Authorized Representative and the Authorized Representative Verifier cannot be the same person.
Do I have to submit an Authorized Representative Verification Form per Plan Sponsor ID or for each Application ID?
An Authorized Representative Verification Form must be submitted for each Plan Sponsor ID. For example, if an individual is an Authorized Representative for two different Plan Sponsors, each of those Plan Sponsors must submit an Authorized Representative Verification Form for its Authorized Representative. Authorized Representative Verification Forms are associated with the Plan Sponsor, not to the individual assigned the role of Authorized Representative. A new Authorized Representative Verification Form must be submitted, not a modified one.
When should I submit an Authorized Representative Verification Form?
An Authorized Representative Verification Form must be submitted when:
- A Plan Sponsor applies to the RDS Program for the first time
- A Plan Sponsor changes their Authorized Representative
- CMS' RDS Center rejects a previously submitted Authorized Representative Verification Form
An Authorized Representative Verification Form may be submitted anytime during the Application Submission Process, but CMS' RDS Center recommends that Plan Sponsors submit it as soon as possible. It will take CMS' RDS Center up to 5 business days after a valid Authorized Representative Verification Form is received to process and approve the form. It is not necessary to submit a new Authorized Representative Verification Form with each new plan year's application.
Note: Plan Sponsors will not be allowed to make a payment request until the Authorized Representative Verification Form has been approved by CMS' RDS Center.
Do all sections of the Authorized Representative Verification Form have to be completed?
Yes, all sections of the form must be completed and legible. A Plan Sponsor's Authorized Representative Verification status will not change from "Incomplete" to "Approved" until CMS' RDS Center receives and approves the form. If there is a problem with the form, CMS' RDS Center will contact the Account Manager.
How do I complete an Authorized Representative Verification Form?
The Authorized Representative being verified must have completed registration in the RDS Secure Web Site. For more information about Registration, go to: Authorized Representative Registration section of Chapter 5 in the RDS User Guide.
To complete an Authorized Representative Verification Form, print out a copy and follow the steps below.
1. Reason for Submission
Check the reason for submission.
Initial Submission – Select this if your organization is submitting an Authorized Representative Verification Form for the first time, for a specific Plan Sponsor ID.
Correcting a Rejected Form – Select this if your organization previously submitted an Authorized Representative Verification Form and received a phone call or e-mail stating that there was an error with the form and you are now submitting a corrected form.
Reassigned Authorized Representative – Select this if your organization had previously submitted an Authorized Representative Verification Form that was approved and you are now re-assigning the Authorized Representative role to another individual.
Other – Select this if the reason for submission is not listed. You must explain why you are sending in the Authorized Representative Verification Form.
2. Authorized Representative Name
Enter the Authorized Representative's name as it appears in the RDS Secure Web Site.
If you do not know how the Authorized Representative's name appears, have them log into the RDS Secure Web Site to verify. Their name will display in the top, left corner of the Plan Sponsor List With Application Summary page.
3. Authorized Representative Title
Enter the Authorized Representative's title.
Note: The Authorize Representative is a user chosen by the Plan Sponsor that the Plan Sponsor has granted the legal authority to bind the Plan Sponsor to the terms of the Plan Sponsor Agreement.
Common examples of positions within the Plan Sponsor organization that are held by the Authorized Representative are:
- Chief Executive Officer (CEO)
- Chief Financial Officer (CFO)
- President
- Human Resources Director
- General Partner
4. Plan Sponsor Name
Enter the Plan Sponsor Name as it appears in the RDS Secure Web Site.
The Plan Sponsor Name is the organization name associated with the Employer Identification Number (EIN) used to establish the Plan Sponsor ID. If you do not know the Plan Sponsor Name, you need to log into the RDS Secure Web Site to verify. The Plan Sponsor Name will display on the Plan Sponsor List With Application Summary page under the Company Name section.
5. Plan Sponsor ID (NOT EIN)
Enter the Plan Sponsor ID as it appears in the RDS Secure Web Site.
The Plan Sponsor ID is the unique number assigned by CMS' RDS Center to each Plan Sponsor that creates a Plan Sponsor account in the RDS Secure Web Site. CMS' RDS Center uses the Plan Sponsor ID to store information, data, and forms submitted by each Plan Sponsor. The Plan Sponsor ID is not the same as the EIN assigned by the Internal Revenue Service or the Application ID. If you are unsure of your Plan Sponsor ID please log into the RDS Secure Web Site to obtain this information. The Plan Sponsor ID will display on the Plan Sponsor List With Application Summary page under the Plan Sponsor ID section.
6. Verifier Name (NOT the Authorized Representative)
Enter the Authorized Representative Verifier's name.
The Authorized Representative Verifier’s name is the name of the individual completing the Authorized Representative Verification Form. The Authorized Representative Verifier who completes and signs this form must be an employee of the Plan Sponsor. For multi-employer plans, the Authorized Representative Verifier may be an employee, or a member of the jointly appointed board of trustees, which includes both labor and management.
The Authorized Representative and the Authorized Representative Verifier cannot be the same person.
7. Verifier Job Title
Enter the Authorized Representative Verifier's job title.
8. Verifier E-mail Address
Enter the Authorized Representative Verifier's e-mail address.
9. Verifier Telephone Number (including area code)
Enter the Authorized Representative Verifier's telephone number, with area code.
10. Verifier Company Address
Enter the Authorized Representative Verifier's company address.
11. Verifier Signature
Sign the Authorized Representative Verification Form.
The Authorized Representative Verifier's signature certifies that this document is a confirmation for purposes of CMS' RDS Program that the individual named in (2) above is acting as the Authorized Representative.
12. Date
Enter the date that the form was completed.
If my organization re-assigns the Authorized Representative role, do I have to submit a new Authorized Representative Verification Form?
Yes, if your organization re-assigns the Authorized Representative role a new Authorized Representative Verification Form must be completed and re-submitted to CMS' RDS Center.
Note: In this situation, you will select the Reassigned Authorized Representative option in the Reason for Submission section.
Where do I send the Authorized Representative Verification Form?
The Authorized Representative Verification Form may be sent to CMS' RDS Center using one of the following methods:
- E-mail - RDS_Forms@cms.hhs.gov (Complete the form, scan and save as an image, and attach to an e-mail.) CMS' RDS Center recommends this method.
- Fax - 646-458-2280
- Address – Retiree Drug Subsidy Center
Attn: AR Verification Unit
P.O. Box 5032
New York, N.Y. 10274-5032
Note: CMS' RDS Center recommends that Plan Sponsors select one submission method. Please do not make multiple submissions as this will delay processing.
How do I know my Authorized Representative Verification Form has been approved?
The status of your Authorized Representative Verification Form can be found on the Application List page. If the Authorized Representative Verification Status and Authorized Representative Verification Status Effective Date have not changed after 5 business days after sending your form, call CMS' RDS Center Help Line for assistance.
Note: If a Plan Sponsor re-assigns the role of Authorized Representative, then the Authorized Representative Verification Status will change to "Incomplete" and a new Authorized Representative Verification Form must be submitted to CMS' RDS Center for the newly assigned Authorized Representative.
Downloads
Authorized Representative Verification Form (pdf, 52KB)
Adobe Acrobat format. You may download a free copy of Acrobat Reader from Adobe.
