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MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 23 Effective Month: September 2023 form may be more appropriate to allow access to information while the applicant or recipient represents themselves. Contact with the applicant or recipient is needed to make this determination, which must be documented in the case record. 2. Self-Designated Representative

A self-designated representative is a person acting responsibly for an applicant or recipient because the physical or mental condition of the applicant/recipient is such that he cannot authorize anyone to act for him nor can he act for himself. Family members or non-relatives with knowledge of the applicant’s or recipient’s circumstances are allowed to self-designate in writing with the use of a form designed for this purpose (DOM-302B). A representative of an organization or a provider cannot self-designate to represent an applicant or recipient, except in cases where the self-designating individual is an owner, operator or employee of a state-owned long term care healthcare facility. All other individuals representing an organization or provider must become legally appointed to represent an individual for health care decisions, in which case the individual becomes the Legal Representative of the applicant or recipient. A self-designated representative must file an application or review form in the name of the applicant/recipient with the self-designated representative providing required information to determine or re-determine eligibility and sign all eligibility-related forms that are required. The self-designated representative will receive all eligibility notices and letters.

NOTE: A parent or primary caretaker relative is allowed to apply for a child without signing the self-designation form authorizing themselves as a representative. 3. Legal Representative A legal representative is someone who has been legally appointed to act on behalf of an applicant or representative. The legal representative must provide documentation of their legal authorization to act for the applicant or recipient, such as a Power of Attorney document, legal guardianship decree, conservatorship decree, a custody decree or other type of court order, and complete a Legal Representative form (DOM-