INCOME MAINTENANCE MANUAL

0105.010.00 SIGNING THE APPLICATION

IM-123 July 28, 2020, IM-75 May 05, 2019, IM-134 November 13, 2017, IM-#35 June 16, 2016, IM#31 April 20, 2015, IM#73 December 12, 2014, IM#15 March 20, 2014, IM#91 November 21, 2012

42 CFR 435.907 under authority of the Social Security Act provides requirements for application, determination of eligibility and furnishing of assistance for MO HealthNet programs.

The Family Support Division requires that applications be made on Family Support Division application forms, and that they are signed under a penalty of perjury.

Use the following to determine who can complete and sign an application for IM programs:

WHO CAN SIGN THE APPLICATION PROGRAM
Applicant Adult Cash Assistance, and All MO HealthNet for the Aged, Blind, and Disabled Programs
Legal Guardian Adult Cash Assistance, and All MO HealthNet for the Aged, Blind, and Disabled Programs
(does not apply if the applicant is deceased)
Conservator Adult Cash Assistance, and All MO HealthNet for the Aged, Blind, and Disabled Programs
(does not apply if the applicant is deceased)
Relative
– due to incapacity of applicant
Adult Cash Assistance and All MO HealthNet for the Aged, Blind, and Disabled Programs
(does not apply if the applicant is deceased)
Authorized Representative Adult Cash Assistance and all MO HealthNet for the Aged, Blind, and Disabled Programs
(does not apply if the applicant is deceased unless appointed by the personal representative, administrator or executor of the deceased applicant’s estate or surviving spouse who has obtained a refusal of letters or who has filed a valid small estate affidavit, see Signing on behalf of a deceased applicant)
Power of Attorney Adult Cash Assistance and all MO HealthNet for the Aged, Blind, and Disabled Programs
(does not apply if the applicant is deceased)
Personal Representative, Administrator or Executor of Estate of Deceased Person Adult Cash Assistance and all MO HealthNet for the Aged, Blind, and Disabled Programs
(when MO HealthNet applicant is deceased see Signing on behalf of a deceased applicant)
Surviving spouse who has obtained a refusal of letters or who has filed a valid small estate affidavit Adult Cash Assistance and all MO HealthNet for the Aged, Blind, and Disabled Programs
(when MO HealthNet applicant is deceased see Signing on behalf of a deceased applicant)

Further explanation and special procedures are as follows:

Application with No Signature

If an application is received with no signature and the address of the applicant is known, the application must be returned for signature. Send the original form back to the applicant, guardian, authorized representative, or relative for signature with the Signature Request Letter within three business days. If a signed application is not returned, no further action is necessary.

NOTE: If the individual has a valid IM-6AR on file with FSD, the unsigned application must be sent to the designated authorized representative and the individual applying for assistance.  See 0803.020.10.20 Duration of Appointment of Representative for information concerning validity of the IM-6AR.  If the individual has reported a legal guardian, the unsigned application must also be sent to the guardian and the individual applying for assistance.

EXAMPLE: July 10th a signed IM-6AR is received by the agency, for an individual who is not currently receiving MO HealthNet assistance. July 20th an unsigned application is received for the individual.  The unsigned application must be sent to the applicant for signature. In addition, a copy of the unsigned application must be sent to the authorized representative designated on the July 10th IM-6AR.

NOTE: Applications with no signature or contact information (address or phone number) cannot be processed.

Signing By Mark

If the signature is by mark, two witnesses are necessary.

Electronic Signature

An electronic signature for web applications is accepted.

Signing By a Relative – All Adult MO HealthNet Programs and Adult Cash Assistance

If the applicant is incapable of signing an application due to physical or mental incapacity, a relative may sign the application. Inform the relative that the applicant is responsible to ensure complete and correct information is provided on the application.

NOTE:  A relative may sign the application, but an Appointment of Authorized Representative (IM6-AR) form must be signed by the applicant. Relatives cannot appoint an authorized representative on behalf of an applicant.

Signing By a Legal Guardian or Conservator

Obtain documentation of legal guardian or conservator status. If the applicant has a court appointed conservator, instruct the conservator to sign and complete the application. If the applicant has a court appointed guardian, either the guardian or the applicant may sign the application. If an interview is needed, conduct the interview with the guardian or conservator. The applicant’s presence is not required.

Signing on behalf of a deceased applicant

If the applicant is deceased, the application must be signed by a court appointed personal representative, administrator or executor of the deceased applicant’s estate or the surviving spouse who has obtained a refusal of letters or has filed a valid small estate affidavit.

NOTE:  If the application is filed after the third month following the month of the applicant’s death, it will be rejected because the prior quarter application period is passed.

A court appointed personal representative, administrator or executor of the deceased applicant’s estate or surviving spouse who has obtained a refusal of letters or has filed a valid small estate affidavit has legal authority to apply for and follow the application process through to resolution, including the Division’s appeal process.

Obtain documentation of appointment as administrator or executor of the estate. Add the court appointed administrator or executor of the deceased applicant’s estate to the Representative List screen (AUTHREP/FMJ1) and Representative Detail screen (FMJG) in FAMIS.

NOTE: Refusal of letters per RSMo 473.090 or a small estate affidavit per RSMo 473.097 are court orders and are administered by the Probate Division of the Circuit Court.  If the validity of the court order is in question send documentation on a Request for Interpretation of Policy (IM-14) form through supervisory channels to MO HealthNet Program and Policy at cole.mhnpolicy@dss.mo.gov.

NOTE:  When an applicant is deceased, a relative, legal guardian, or conservator cannot appoint another person or agency to be an authorized representative for the applicant. The court appointed personal representative, administrator or executor of the estate or surviving spouse who has obtained a refusal of letters or has filed a valid small estate affidavit may appoint an authorized representative. See Authorized Representative(s) below and Income Maintenance Manual section 0130.020 AUTHORIZED REPRESENTATIVE(S) FOR MO HEALTHNET.

See Income Maintenance Manual sections 0105.040.15 Death after Application and 0105.040.20 Application for Deceased Persons for more information.

Signing by an Authorized Representative (Adult Cash Assistance and all MO HealthNet for the Aged, Blind, and Disabled Programs)

See Income Maintenance Manual section 0130.020 AUTHORIZED REPRESENTATIVE(S) FOR MO HEALTHNET for information on who can appoint an authorized representative, who can be an authorized representative, duties and responsibilities of the agency and authorized representative, and the duration of the Appointment of Authorized Representative.

An applicant may designate an individual(s) to apply for MO HealthNet on their behalf. Obtain an IM6-AR for appointment of authorized representative. The authorized representative is recognized by the FSD when a completed Appointment of Authorized Representative IM-6AR form is received. A FSD employee may contact the applicant to verify the written authorization. The IM-6AR form must be signed prior to the Authorized Representative signing the application.

If the applicant has an appointed authorized representative, either the applicant or the authorized representative can sign and complete the application.

The authorized representative may sign the application form, complete and sign the eligibility statement, or complete the FAMIS application interview and sign the interview summary. If further information or documentation is needed, provide a Request for Information (FA-325 or IM-31A) form to the authorized representative, and provide a copy of the form to the applicant. Forms that authorize release of information to the FSD such as the Financial Information Request (FA302 or IM-7) form must be signed by the applicant or by the individual in the Eligibility Unit whose information must be verified. The authorized representative has the responsibility to obtain these signed releases as part of the application process.

If needed, an interview may be conducted with the applicant and/or the authorized representative. The applicant’s presence at the interview is not required when an authorized representative has been appointed.

Add the appointed Authorized Representative(s) to the Representative List screen (AUTHREP/FMJ1) and Representative Detail screen (FMJG) in FAMIS. Multiple Authorized Representatives may be entered.

NOTE:   An applicant who applies on their own may designate an Authorized Representative at any time to assist them in completing the application process.

NOTE: Death of an applicant who has appointed an authorized representative to apply on his/her behalf voids the appointment of an authorized representative. If an application is not submitted prior to death of the applicant, an authorized representative may not file the application. However, the authorized representative may assist with an existing application filed prior to the death of the applicant/participant.

See Section 0105.040.15 Death after Application and 0105.040.20 Application for Deceased Persons for more information.

Adding a Person to an Active Case

A signed application is not required to add a person to an active MO HealthNet or Temporary Assistance case. Although the process for adding a person to an active case is completed in FAMIS by making entries on the Application Request (REQUEST/FM0G) screen, a request to add-a-person is considered an interim change.

As an interim change, mandatory assistance group members must be added to the Eligibility Unit to determine continued eligibility of the assistance group. When an individual is a mandatory member of an existing assistance group, the individual will be considered to be included in the active case as of the date the individual is required to be included in the assistance group.

Necessary verification to determine continued eligibility must be requested using a Request for Information (FA325 or IM-31A) form. See Income Maintenance Manual sections 1000.000.00 DECEMBER 1973 ELIGIBILITY REQUIREMENTS, and 0225.000.00 INTERIM CONTACTS (TA).