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MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |94 Effective Month: September 2018 • The applicant must sign a DOM-301A, Authorization to Release Medical Information, for the number of providers identified on the DOM-323. In addition, the applicant must sign, but not date, two additional “Authorization to Release Medical Information” forms. o Signatures on blank releases are required so that DDS will have sufficient releases for providers indicated on the DOM-323 and other providers they feel it necessary to contact without having to delay the process to get additional releases. Medicaid Specialists must explain this reasoning to applicants. o If an applicant refuses to sign blank forms, have the applicant complete the provider’s name and sign the form. Explain that there could be a delay in the process if the applicant has to be contacted for any additional releases that may be needed. o Signatures required on the DOM-301A, Authorization to Release Medical Information: The applicant or an individual who has the legal authority to act on behalf of the applicant, such as a parent, power of attorney, agency or individual holding custody, or conservatorship, must sign the release. When someone other than the applicant signs the release, the individual must sign his name (not the name of the applicant) and indicate his relationship to the applicant. If the applicant is unable to sign the release and the designated representative signs in the applicant’s place, the authorized representative must state why the applicant is unable to sign his name, e.g., “patient unconscious”, “patient senile”, etc. If a representative signs the DOM-301A, attach a copy of the appropriate DOM-302 Designated Representative Statement”. If the DOM-302 is signed as self-designation, there must be an explanation of why the applicant did not sign the 302 before medical information is released. If the release is signed with an “X”, two witnesses must also sign.