MEMORANDUM

DISCUSSION:

The Appointing an Authorized Representative (IM-6AR) form has been revised.  The revised form is to be used for all MO HealthNet for the Aged, Blind, and Disabled (MHABD) individuals wishing to name an authorized representative.

Section 1:  The participant names his/her authorized representative (AR) and selects what authority the AR will have. 

• Helping with MO HealthNet application;
• Acting ongoing for annual reviews, reporting changes, etc;
• Or both

Space is provided for the participant and his/her spouse to sign appointing the AR.

Section 2:  The participant authorizes release of Protected Health Information (PHI) and other information as necessary to establish or maintain eligibility for MHABD programs. 
Space is provided for the participant and his/her spouse to sign authorizing release of PHI

NOTE: It is very important that the participant and his/her spouse sign this section if the AR will be receiving any notices or information from Family Support Division.  Notices will not be sent to the AR of a couple case if this section is not signed by both the head of house hold and the spouse.  They are not required to sign this section, but notices cannot be sent if they do not.

This section is not necessary if the individual/organization being appointed is a medical provider, or the participant's attorney, attorney-in-fact, guardian or conservator, or court appointed public administrator.

Section 3: The AR must agree and accept the appointment as authorized representative.  Part of accepting is acknowledging and understanding the AR is required to protect the privacy of the participant they represent.

Effective with this memo do not accept older versions of the IM-6AR. 

At each reinvestigation, review the Representative List (AUTHREP) screen in FAMIS.  If the begin date of the authorized representative listed is prior to the date of this memo, a new form is necessary.  It is not necessary for a medical provider, or the participant's attorney, attorney-in-fact, guardian or conservator, or court appointed public administrator.  Take the following steps to request an updated form.

1. Manually send a Request for Information (IM-31A) along with the revised IM-6AR to the participant with instructions to complete, sign, and return the IM-6AR within 10 days. 
2. Make a comment on EUMEMROL and AUTHREP screens, indicating it sent and when it is due.
3. If the IM-6AR is returned, end the existing AR and re-enter with the new information.
4. If the IM-6AR is not returned, take action to end the AR.

NOTE: The staff member who sends the IM-31A and IM-6AR to the participant is responsible to verify if the IM-6AR was returned, and take actions instructed above.

 

NECESSARY ACTION:

• Review this memorandum with appropriate staff.
• Begin using the revised forms immediately.

ATTACHMENTS:

• Appointing an Authorized Representative (IM-6AR)

 

PL/vb