Family and Children's Medicaid MA-3205 CONDUCTING A FACE-TO-FACE INTAKE INTERVIEW
II. Who may apply
The following individuals have the right to make application:
A. The individual, including a minor, who is applying on his own behalf.
B. Any representative who alleges that he is acting on an individual’s behalf.
If a representative is making the application, it is preferable (though not required) that the representative has some knowledge of the individual’s situation.
1. Representatives may include, but are not limited to:
c. Staff at medical facilities.
2. Request a written statement by the applicant/recipient from any non-relative who is applying on behalf of an individual authorizing the non-relative to act as his authorized representative. Do not refuse to take or deny the application if the statement is never provided. If the statement is unavailable at application, request the statement as additional information.
3. Explain to representatives who are not financially responsible budget unit members that information regarding the application and/or ongoing case cannot be released to him without authorization. There must be a consent form authorizing the release of the information signed by the individual applying for or receiving Medicaid. Information can be released without a consent form if the representative has power of attorney or guardianship for the individual. See DMA-5018 Designation of Authorized Representative, for a suggested form.
REVISED 10/01/11 – CHANGE NO. 17-11
4. Any time an application is being made by someone on the individual’s behalf, the following questions should be addressed during the interview:
a. Why is the individual not applying for himself?
b. Is the individual able to be interviewed by the Income Maintenance Caseworker either via the telephone or a home visit? If not, why?
c. Does the individual have a power or attorney, legal guardian or other authorized representative? If yes, follow instructions in MA-3430, Notice and Hearings Process, III. If no, see 3. above.
d. Is the individual able to sign the DMA-5018 Designation of Authorized Representative, or similar authorization form himself? If not, why?