IM-010 January 09, 2018, IM-33 April 20, 2015
At the time of application or at any other time, an applicant/participant may elect to appoint an authorized representative to:
Assist and/or represent them in the MO HealthNet application process, or the redetermination or review of eligibility;Act on behalf of the applicant/participant in other actions on the MO HealthNet case; andReceive copies of the applicant/participant’s notices and other communications
The applicant/participant may use an authorized representative to perform only the following:
Apply for benefits or services and supply information to complete an eligibility determination;Complete and submit reinvestigation/redetermination forms;Represent the applicant/participant in an interview;Notify the FSD of any changes;Obtain any information that the FSD would provide to any applicant/participant upon execution of an appropriate release or releases as required by state or federal law or regulation (See Income Maintenance Manual sections 0130.005.00 CONFIDENTIALITY and 0130.005.10 Health Insurance Portability and Accountability Act. If the applicant/participant wants to release protected health information, the 650-2616 (HIPPA) Authorization for Disclosure of Consumer Medical/Health Information form must be completed.);Examine any documents the applicant/participant may request or be able to access, upon execution of an appropriate release or releases as required by state or federal law or regulation (See Income Maintenance Manual sections 0130.005.00 CONFIDENTIALITY and 0130.005.10 Health Insurance Portability and Accountability Act. If the applicant/participant wants to release protected health information, the 650-2616 (HIPPA) Authorization for Disclosure of Consumer Medical/Health Information form must be completed.);Receive notification of any decision;Appeal any ruling from the Department of Social Services to the Administrative Hearings Unit (AHU), Division of Legal Services (DLS);Make any request or give any report, change or notice to the FSD or the AHU; andRepresent the applicant/participant in a hearing before a DLS hearing officer.NOTE: Do not release participant information to another person until a valid designation of authorized representative, including HIPAA notification has been signed and received by the Division. 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.
The appointment of an authorized representative does not preclude FSD staff from contact with the applicant/participant as needed to conduct the business of the agency with regard to the application, review, or other agency action.
An applicant/participant:
Cannot appoint an authorized representative if the applicant/participant is determined incompetent by a court. (In those cases, the Guardian or Conservator would appoint the authorized representative.)Must willingly and knowingly appoint an authorized representative. If the designation of an authorized representative was created under duress or undue influence, or was induced by fraud, it is considered void.Will be financially and legally responsible for all information provided or omitted, and all actions taken or omitted by the authorized representative.Must sign an IM-6AR or other designation form to appoint an authorized representative. The signature can be handwritten, stamped, electronic, telephonically recorded (when available), or by any other method accepted by the FSD. An unsigned IM-6AR or designation form is not a valid appointment of an authorized representative.The IM-6AR or other designation form must include the name, address and telephone number of the authorized representative or organization designated to serve as the authorized representative.The IM-6AR or other designation form can be accepted by mail, fax or any other commonly available electronic means.If an IM-6AR is not used, the other designation form must 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; andAn 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.”
The authorized representative is effective with the date the completed IM-6, IM-6AR or other designation form is received by the FSD. The FSD may contact the applicant/participant or other individuals signing the IM-6AR or other designation form on behalf of the applicant/participant to verify the appointment of an authorized representative. NOTE: For applications/cases in Family Assistance Management Information System (FAMIS), upon receipt of a completed IM-6, IM-6AR, IM-6ARO or other designation form add Authorized Representative information on the Representative List screen (AUTHREP/FMJ1) and Representative Detail screen (FMJG).For applications/cases in Missouri Eligibility Determination and Enrollment System (MEDES), upon receipt of a completed IM-6AR, IM-6ARO or other designation form add a comment to the client’s Person Page, under Notes. List the authorized representatives name, address and telephone number as well as the date the IM-6AR, IM-6ARO or other designation form was signed and received (at this time the authorized representative evidence is not functioning in MEDES so manual notices must be sent to the authorized representative).
Can appoint an individual or an organization as an authorized representative.If an individual is appointed as an authorized representative, the individual must be 18 years of age or older.If an organization is appointed as an authorized representative, the organization must provide in writing the name, address and phone number of an individual within the organization serving as a contact person for the FSD within ten (10) days of appointment of the organization as the authorized representative. The organization must notify the FSD in writing of any change in the name and contact information for the designated contact person within 10 days of the change. The IM-6ARO is the preferred method to notify the FSD of the contact person and any subsequent changes.
May appoint more than one individual or organization to serve as the authorized representative at any given time. NOTE: If there is conflicting information or instructions from more than one authorized representative, the FSD must consult with the applicant/participant and/or the authorized representatives to resolve the conflict.EXCEPTION: When the applicant/participant is represented by an attorney the FSD will consult with the attorney before consulting with the applicant/participant if conflicting information is received.Must notify the FSD of any change in the address and phone number of the authorized representative within 10 days of the known change. (The authorized representative may provide this information on behalf of the applicant/participant.)
Do NOT require an IM-6AR or other authorized representative designation form when the applicant/participant is represented by:
A public administrator or other individual appointed by the court as guardian and/or conservator. Obtain documentation of the court appointment.An authorized representative cannot represent an applicant/participant who has a Guardian and/or Conservator recognized by Missouri law, unless the Guardian and/or Conservator appointed the authorized representative.
A person acting as attorney-in-fact or agent under a Power of Attorney (POA), when the applicant/participant has given that person written authorization to act on their behalf in financial, business or legal matters. Review the POA document to determine if the POA is currently in effect and if the applicant/participant has given their attorney-in-fact/agent the authority to act in this capacity.The attorney-in-fact/agent may appoint an authorized representative when allowed to act in that capacity.
An attorney at law licensed by the State of Missouri. The attorney must file a written entry of appearance with the FSD.NOTE: Attorneys who do not file a written entry of appearance, but wish to act on an applicant/participant’s behalf must provide other appropriate documentation of their capacity as representative.An individual or organization to whom a court of competent jurisdiction has issued letters of administration or testamentary on behalf of the deceased participant or a surviving spouse when a valid court order or valid small estate affidavit has been received.The individual, organization or surviving spouse may appoint an authorized representative
The authorized representative must not:
Make a willfully false statement,Misrepresent,Willfully conceal,Fail to report, or fail to disclose any fact or event required to be reported by any law, regulation, or rule of this State or the United States.Transfer the appointment or re-delegate his or her authority to represent the applicant/participant to another individual or organization.
An appointment of authorized representative is only valid with the DSS. It does not permit an authorized representative to represent or appear for the applicant/participant in any court of law in the State of Missouri.