How To Submit an Authorized Representative Verification Form - Updated 01/31/2008
- 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 Identification Number or per Application Identification Number?
- 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 individual listed on the RDS application as the Authorized Representative is authorized to act on the Plan Sponsor's behalf. An Authorized Representative MUST be an individual employed by the Plan Sponsor to whom the Plan Sponsor has granted the legal authority to bind the Plan Sponsor to the terms of the Plan Sponsor Agreement in the RDS application. Examples of the Authorized Representative include the Sponsor's general partner, CFO, CEO, president, Human Resources Director, or an individual who holds a position of similar status and authority within the Plan Sponsor's organization. For multi-employer plans, the Authorized Representative does not have to be an employee of the Plan Sponsor, but may be a member of the jointly appointed board of trustees, which includes both labor and management trustees.
Who may complete an Authorized Representative Verification form?
The Authorized Representative Verification form must be completed by a Verifier who is defined as an individual, other than the Authorized Representative, with sufficient authority from the Plan Sponsor to verify that the Authorized Representative, listed on the RDS application, is permitted to act on the Plan Sponsor's behalf for purposes of the RDS Program. If this individual IS NOT an employee of the company, they MUST be listed as the Account Manager in the RDS Secure Web Site to be accepted as the Verifier; otherwise the form will not be approved.
Do I have to submit an Authorized Representative Verification form per Plan Sponsor Identification Number or per Application Identification Number?
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 to the Plan Sponsor, not to the individual assigned the role of Authorized Representative. Please note that the provided verification form must be submitted as is (i.e., not modified).
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 process, but CMS' RDS Center recommends that Plan Sponsors submit it as soon as possible. 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. Your Plan Sponsor's Authorized Representative Verification status will not change from Incomplete to Approved until CMS' RDS Center receives and approves your form. If there is a problem with your form, CMS' RDS Center will contact your organization within 10 business days of receipt of your form.
How do I complete an Authorized Representative Verification form?
To complete an Authorized Representative Verification form, print out a copy and follow the steps below.
1. Indicate Reason for Submission
Select the reason for submission.
Initial Submission – Indicate this submission selection if your organization is submitting an Authorized Representative Verification form for the first time, for a specific Plan Sponsor ID.
Correcting a Rejected Form – Indicate this submission selection 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 – Indicate this submission selection 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 – Indicate this submission selection if the reason for submission is not listed. You must explain why you are sending in the Authorized Representative Verification form.
2. Authorized Representative's 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 With Application Summary page.
3. Authorized Representative's Title
Enter the Authorized Representative's title.
An Authorized Representative MUST be an individual employed by the Plan Sponsor to whom the Plan Sponsor has granted the legal authority to bind the Plan Sponsor to the terms of the Plan Sponsor Agreement in the RDS application. Examples of the Authorized Representative include the Plan Sponsor's general partner, CFO, CEO, president, Human Resources Director, or an individual who holds a position of similar status and authority within the Plan Sponsor's organization. For multi-employer plans, the Authorized Representative does not have to be an employee of the Plan Sponsor, but may be a member of the jointly appointed board of trustees, which includes both labor and management trustees.
4. Plan Sponsor Name
Enter the Plan Sponsor Name as it appears in the RDS Secure Web Site.
The Plan Sponsor Name is the business 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 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 the RDS Center to each Plan Sponsor that creates a Plan Sponsor account in the RDS Secure Web Site. The 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 Number. 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 With Application Summary page under the Plan Sponsor ID section.
6. Verifier's Name (may NOT be the Authorized Representative)
Enter the Verifier's name.
The Verifier is the individual completing the Authorized Representative Verification form. The Authorized Representative Verification form must be completed by an individual, other than the Authorized Representative, with sufficient authority from the Plan Sponsor to verify that the Authorized Representative, listed on the RDS application, is permitted to act on the Plan Sponsor's behalf for purposes of the RDS Program. If this individual IS NOT an employee of the company, they MUST be listed as the Account Manager on the RDS Secure Web Site to be accepted as the Verifier; otherwise the form will not be approved.
7. Verifier's Job Title
Enter the Verifier's job title.
8. Verifier's E-mail Address
Enter the Verifier's e-mail address.
9. Verifier's Telephone Number (including area code)
Enter the Verifier's telephone number, with area code.
10. Verifier's Company Address
Enter the Verifier's business address.
11. Verifier's Signature
Sign the Authorized Representative Verification form.
The Verifier's signature certifies that this document is a confirmation for purposes of the CMS' RDS Program, that the individual named in (2) above is acting as the Authorized Representative (An Authorized Representative MUST be an individual employed by the Plan Sponsor to whom the Plan Sponsor has granted the legal authority to bind the Plan Sponsor to the terms of the Plan Sponsor Agreement in the RDS application. Examples of the Authorized Representative include the Plan Sponsor's general partner, CFO, CEO, president, Human Resources Director, or an individual who holds a position of similar status and authority within the Plan Sponsor's organization. For multi-employer plans, the Authorized Representative does not have to be an employee of the Plan Sponsor, but may be a member of the jointly appointed board of trustees, which includes both labor and management trustees).
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 via:
- Fax - 646-458-2280
- E-mail - RDSpayment@cms.hhs.gov (complete the form, scan and save as an image, and attach to an e-mail.) CMS' RDS Center recommends this method.
- U.S. Mail – Retiree Drug Subsidy Center
Attn: Authorized Representative 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 after 10 business days, of receipt of your form, the Authorized Representative Verification Status and Authorized Representative Verification Status Effective Date have not changed, you may e-mail your questions to: RDSpayment@cms.hhs.gov.
Note: If a Plan Sponsor re-assigns the role of Authorized Representative, then the Authorized Representative Verification Status will display 'Incomplete' and a new Authorized Representative Verification form must be re-submitted to CMS' RDS Center for the newly assigned Authorized Representative.
Downloads
Authorized Representative Verification form (pdf, 72KB)
Adobe Acrobat format. You may download a free copy of Acrobat Reader from Adobe.
