Authorized Representative

(a) A individual who chooses an authorized representative (AR), as defined in He-W 601.01(w), to help with some or all the responsibilities of applying for or receiving medical assistance shall provide all of the following information in writing:

(1) The name, address, and telephone number of the AR;

(2) The duties that the AR will carry out, as specified in (c) below;

(3) The individual's relationship to the AR;

(4) A statement signed and dated by the individual acknowledging:

a. His or her responsibility for any errors, omissions, failures to report information to DHHS, or inaccurate information reported to DHHS by the AR;

b. That if the AR uses the individual’s benefits without permission, these benefits will not be replaced by DHHS;

c. That the person the individual names as the AR will continue to act for the individual until the individual or the AR tells DHHS of a change; and

d. Comprehension of the individual’s choice of AR and the duties assigned to that AR; and

(5) A statement signed and dated by the AR:

a. Agreeing to accept the responsibilities designated by the individual;

b. Acknowledging that the AR understands that:

1. Proof of the AR’s identity is required;

2. If disqualified for a program violation, the person identified as the AR can no longer act as an AR unless there is no one else suitable to represent the individual; and

3. The AR will continue to act as an AR for the individual until the AR or the individual tells DHHS of a change.