Page 2146

7 AAC 100.004. Identifiable application for Medicaid. (a) The department will not act on a request for Medicaid eligibility or coverage until the department receives an identifiable application. An identifiable application must be made on a form provided by the department for the purpose of applying for Medicaid. That application form must

(1) include

(A) a legible name and address; and

(B) a signature or witness mark of the applicant or the applicant’s authorized representative appointed under 7 AAC 100.006(a);

(2) be submitted by

(A) the applicant;

(B) an authorized representative appointed under 7 AAC 100.006(a); or

(C) an individual acting responsibly in the place of the applicant in accordance with 7 AAC 100.006(b); and

(3) be received by

(A) a district office of the division handling public assistance matters in the department;

(B) a fee agent or other department designee; or

(C) if the child is in the department’s protective custody, the office of the department handling matters for children in the department’s protective custody. (b) Before the department will determine eligibility for Medicaid, the application form must be signed by

(1) the applicant;

(2) the caretaker relative, if the application is for a dependent child under an eligibility category in 7 AAC 100.102(a) or (c);

(3) both parents, if

(A) the application is for a dependent child under an eligibility category in 7 AAC 100.102(a) or (c) who is residing with both parents in the same home; and

(B) the financial needs, resources, and income for both parents are used to determine eligibility for the dependent child;