MEMORANDUM

DISCUSSION:

This memorandum introduces the Nursing Facility Authorization Form (NFAF) that will enable Family Support Division (FSD) staff to share information about a MO HealthNet customer’s case with the nursing facility in which the customer resides. By signing this form, the customer is giving FSD permission to share case information with the nursing facility without appointing the facility as his/her authorized representative.  “Case information” includes any documents and information necessary to complete the eligibility determination. The form is also HIPAA-compliant and allows FSD to share Protected Health Information with a nursing facility, if it is necessary for the eligibility determination.

“Nursing facility” includes a skilled nursing facility, intermediate care facility, assisted living facility, residential care facility, a state mental hospital, a state institution for the developmentally disabled, or a JCAHO-accredited facility providing psychiatric care to a person under age 21.

The NFAF can be signed by the customer or his/her authorized representative, legal representative, or power of attorney. If the customer has a legal guardian or conservator, the form must be signed by the guardian or conservator to be valid. If the NFAF is signed, FSD staff must send a copy of the form to the customer and/or the person who signed it on the customer’s behalf. Staff should enter a comment on the Eligibility Unit Member Role (FM3Z/EUMEMROL) screen with comment titled “Nursing Facility Authorization Form.” The comment should state that the NFAF has been signed, identify the nursing facility authorized to receive information, and the person who signed the form, along with the date on which the authorization expires.

The form is optional and does not create an authorized representative. Under the section “Your Rights with Respect to this Authorization,” the customer is given the option to bar FSD from disclosing his/her alcohol and drug abuse treatment records by initialing the box provided. Full authorization can be revoked by the customer through a written request to the nursing facility and the DSS Privacy Officer at PO Box 1527, Jefferson City, MO 65102.

A dropdown list at the bottom of the form allows Vendor Units to enter their contact information by selecting it from the list. Contact information can also be entered manually for use by non-Vendor offices.

NECESSARY ACTION:

• Review the memorandum with appropriate staff.

Attachment:

• Nursing Facility Authorization Form

AC/ad