Page 2

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD D-301 APPLICATION An application must contain: • The applicant’s name; • Address; and • Signature. 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. Applications for the Medicare Beneficiary program received through the Low-Income Subsidy (LIS) referral process do not require a signature. The applicant’s signature is obtained by Social Security Administration (SSA). 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 A/R. 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 them of the application, the hospital, nursing home or county agency representative and request any eligibility information to assist in processing the case. D-301 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 APPLICATION