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MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |201

Effective Month: December 2016 DOM APPLICATION FORMS (Continued) • For ABD purposes, the Application for Mississippi Medicaid Aged, Blind and Disabled Medicaid Programs is used. • The MAGI-related and ABD applications forms may be a paper version, an electronic version or an exact facsimile of the appropriate form. • Applications filed for Medicaid coverage through other agencies or entities have their own Medicaid applications, such as SSI or HPE. The application form is a legal document, completed by the applicant or representative that signifies intent to apply and: • Is the official agency document used to collect information necessary to determine eligibility; • Is the applicant’s formal declaration of financial and other circumstances at the time of application; • Is the applicant’s certification that all information provided is true and correct; • Provides notice to the applicant of his rights and responsibilities; and • May be introduced as evidence in a court of law. 101.03.03 SIGNATURE REQUIREMENTS An application form must be signed to be considered a valid application. The signature does not have to be an original signature since applications are allowed to be submitted via means other than on an original paper form; however, a valid signature by someone authorized to apply for Medicaid or CHIP is required. Signed and unsigned applications are treated differently, as specified below. If an applicant is unable to write his/her name, the form may be signed with an “X” mark; however, a witness signature is required. If an applicant is incompetent (adjudged by a court) or incapacitated (due to a physical or mental condition), these conditions require that someone be named to officially represent the applicant, as addressed in “Representatives Authorized to Act for an Applicant.”