1801.010.00 Appointing an Authorized Representative – DSS Manuals

IM-103 July 11, 2022

At the time of application or at any other time, a participant may choose to appoint an authorized representative to:

complete and submit an application

assist and/or represent them in the MO HealthNet (MHN) application process, or the redetermination or review of eligibility

act on behalf of the participant in other actions on the MHN case

receive copies of the participant’s notices and other communications from Family Support Division (FSD)

If indicated on the Appointing an Authorized Representative (IM-6AR) form, the authorized representative may act on behalf of the participant to:

apply for benefits and supply information to complete an eligibility determination

complete and submit renewals and reviews

represent the participant in an interview

notify FSD of any changes

examine and obtain any documents or information from the participant’s record. This may require additional release(s), as required by state or federal law or regulation See 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 MO 650-2616 (HIPAA) Authorization for Disclosure of Consumer Medical/Health Information form must be completed.

request a hearing and participate in the hearing, including representing the participant and providing additional evidence

NOTE: Do not release participant information to another person until verifying that they are an authorized representative.

The participant’s spouse or other related adult member included in the case do not require an IM-6AR. See below for details regarding the participant’s attorney, attorney-in-fact, guardian, conservator, or court appointed public administrator.

Participant’s Rights and Responsibilities

A participant retains all rights to their case, even if an authorized representative is appointed. Participants can still contact FSD, make changes, and apply on their own behalf. FSD retains the right to contact the participant in addition to the authorized representative.

A participant:

cannot appoint an authorized representative if the participant is determined incompetent by a court. In those cases, an authorized representative must be appointed by the guardian or conservator.

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 notify 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 participant.

Authorized Representative’s Rights and Responsibilities

The authorized representative must not:

make a willfully false statement

misrepresent the participant

willfully conceal information

fail to report or disclose any fact or event required to be reported by any law, regulation, or rule of Missouri or the United States

An appointment of authorized representative is only valid with the Department of Social Services (DSS). It does not permit an authorized representative to represent or appear for the participant in any court of law in the State of Missouri.

Designation Forms

A participant must sign an Appointing an Authorized Representative (IM-6AR) or another 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 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 another designation form is used it 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 An 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 must 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 status is effective with the date the completed IM-6AR or other designation form is received by FSD. FSD may contact the participant or other individuals signing the IM-6AR or other designation form to verify the appointment of an authorized representative.

NOTE: Upon receipt of a completed IM-6AR, or other designation form, add Authorized Representative information into the eligibility system.

Organizations as an Authorized Representative

Participants can appoint an organization as an authorized representative.

Within ten (10) days, the organization must provide in writing the name, address, and phone number of an individual within the organization serving as a contact person for FSD.

The organization must notify FSD in writing of any change in the name and contact information for the designated contact person within ten (10) days of the change.

Other Types of Representatives

Do NOT require an IM-6AR or other authorized representative designation form when the participant is represented by:

Parent or caretaker relative of MO HealthNet Disabled Child (MHDC) participant (under age 18) An IM-6AR is required for a parent or caretaker relative once the participant reaches age 18.

public administrator, guardian, conservator, or other individual appointed by the court Obtain documentation of the court appointment. A guardian or conservator can appoint a third party as an authorized representative.

person acting as attorney-in-fact or agent under a Power of Attorney (POA), when the 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 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.

attorney at law licensed by the State of Missouri. The attorney must file a written entry of appearance with FSD associated with a relevant legal proceeding, such as an administrative hearing. Attorneys who do not file a written entry of appearance, but wish to act on a participant’s behalf must provide other appropriate documentation of their capacity as representative as per 13 CSR 40-2.015(18)(B).

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

Multiple Authorized Representatives

Participants may appoint more than one individual or organization to serve as the authorized representative at any given time.

If there is conflicting information or instructions from more than one authorized representative, FSD must consult with the participant and/or the authorized representatives to resolve the conflict.

EXCEPTION: When the participant is represented by an attorney, FSD will consult with the attorney before consulting with the participant if conflicting information is received.