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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL The Division must accept applications signed by: • An adult who has a parent/dependent child (under the age of 19) relationship or tax relationship to the applicant(s); • An A/R; • If the applicant is a minor or incapacitated, someone acting responsibly for the applicant; • An emancipated minor; or • The spouse/domestic partner of an individual. Electronic, including telephonically recorded, signatures and handwritten signatures transmitted via any other electronic transmission are acceptable. Applicants who cannot sign their name must have their mark witnessed by at least one (1) other person. Applicants with no ability to understand what they are signing must have a competent adult family member sign for them. Example: [customer name] by [family member name]. If there are no family members or the existing family members do not wish to assist the applicant, the hospital, nursing home or county agency social service staff may sign on behalf of the applicant. Example: [customer name] by [the hospital, nursing home or county agency social service worker name] In this case, a public guardian referral is required. When applicants are unable to designate an A/R and there are no family members or the existing family members do not wish to assist the applicant, the hospital, nursing home or county agency social service staff may designate themselves as an authorized representative. The hospital, nursing home or county agency must make a reasonable effort to contact family members of the applicant for information to help determine eligibility. The hospital, nursing home or county agency must provide the names and addresses of family members they contacted or tried to contact. The case manager will send Form 2534 Relative Inquiry Letter to the relatives advising of the application, the hospital, nursing home or county A/R and request any eligibility information to assist in processing the case. D-101.1 Unsigned Applications An application which is not signed by the head of household, or an A/R is an inquiry only. Staff should make a reasonable attempt to contact the Head of Household (HOH), or A/R to obtain a signature telephonically via all phone number(s) available on the application and the AMPS system. If no contact is made, do not date stamp the application, it is an inquiry only. The application is incomplete and should not be retained. NOTE: Unsigned applications received for a case with open benefits must be retained and evaluated for changes only. D-101.2 No Program Selected If the application is signed but no program is selected, staff must register and evaluate all applicable Medicaid programs for all listed household members, using prudent person principle. D-101 MAGI APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 25 July MTL 07/25 APPLICATION