DEPARTMENT OF SOCIAL SERVICES
FAMILY SUPPORT DIVISION
PO BOX 2320
JEFFERSON CITY, MISSOURI
- TO: ALL FAMILY SUPPORT DIVISION OFFICES
- FROM: PATRICK LUEBBERING, DIRECTOR
- SUBJECT: APPOINTING AN AUTHORIZED REPRESENTATIVE ON ANOTHER TYPE OF DESIGNATION FORM
- MANUAL REVISION #10
This memorandum introduces updates to the General Information manual section 0130.020.10 Appointment of an Authorized Representative to clarify a participant may designate an authorized representative without using the Appointing an Authorized Representative (IM-6AR) form or the Appendix C of the IM-1SSL MAGI application.
The Family Support Division (FSD) must accept the designation of an authorized representative on forms other than the IM-6AR or the Appendix C of the IM-1SSL MAGI application if all the necessary information is included on the document provided.
Missouri regulation 13 CSR 40-2.015 requires the alternative designation form to include:
- The name of the person or organization designated to serve as the authorized representative;
- The address of the authorized representative and the mailing address of the authorized representative (if different);
- A phone number for the authorized representative; and
- An attestation substantially in the following format: “In appointing my authorized representative, I understand that I will be legally bound and responsible for the actions of my appointed representative with respect to my application for or participation in the MO HealthNet program.” The attestation shall also contain or be accompanied by a signed authorization compliant with the Health Insurance Portability and Accountability Act (HIPAA) for the Department of Social Services to release protected health information to the authorized representative.
If staff has any questions about whether an appointment conforms to this language, they must submit to the MO HealthNet Program & Policy Unit for review.
FSD will not release participant information to an authorized representative until FSD has received a HIPAA compliant authorization and designation of authorized representative. This does not apply to a request for release of participant information from the participant’s attorney, spouse, attorney-in-fact, guardian, conservator, or court appointed public administrator.
- Review this memorandum with appropriate staff.