Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: UPDATED FORMS FOR APPOINTING AN AUTHORIZED REPRESENTATIVE (IM-6AR)
The IM-6AR has been updated and is to be used for all Family Support Division (FSD) programs.
Changes to the IM-6AR include:
- Allowing a signed IM-6AR to be submitted within 90 days of the signature date according to MO HealthNet (MHN) policy
- A new option for an authorized representative to apply for MHN with no ongoing authorized representative rights or responsibilities
- Updated language for participant’s authorization to be represented
- Updated language to allow the participant and the authorized representative to attest that an electronic signature has the same legal effect as a written signature
- A new field for an authorized representative to provide an email address
The IM-6AR with a revision date of 11/2019 is now obsolete. FSD will accept the obsolete form until 9/30/2022. After 9/30/2022, all new authorized representatives must use the form with a revision date of 4/2022.
The updated IM-6AR is available in large print (IM-6AR-LP) and Spanish (IM-6AR (Spanish)) for participant and staff use. The IM-6AR, IM-6AR-LP, and IM-6AR (Spanish) have been updated in the public forms manual and the internal forms manual.
- Review this memorandum with appropriate staff.
- Discard and destroy blank IM-6AR forms with 11/2019 (or older) revision date.
- Begin using IM-6AR with 4/2022 revision date immediately.
- Share with community partners and contacts.
Correction (issued June 17, 2022): An earlier version of this memo stated “The IM-6AR can be ordered by designated staff from the E-store”. The IM-6AR (4/2022) cannot be ordered from the E-store. FSD staff and offices should print the updated versions from the public forms manual.