B-3220 Who May Sign an Application for Assistance

Revision 16-3; Effective Sept. 1, 2016

An individual who may complete or sign an application for an applicant may not be on the list of people to whom HHSC can release the applicant’s individually identifiable health information. See section C-5000 , Personal Representatives, for individuals who may receive or authorize the release of an applicant’s individually identifiable health information under HIPAA privacy regulations.

An applicant, authorized representative or someone acting responsibly for the applicant (if the applicant is incompetent or incapacitated) may sign an application for assistance. The application for assistance must be signed under penalty of perjury.

If an applicant has a guardian, the guardian must:

sign the application for assistance;

obtain a copy of the guardianship papers; and

work with the guardian in the eligibility process.

If an application is signed by someone other than the applicant or the applicant’s guardian, power of attorney, family member, or a friend who is knowledgeable of the applicant’s finances, the individual must provide a Form H1003 , Appointment of an Authorized Representative , signed by the applicant, or evidence of:

authority to complete and sign an application on behalf of an applicant;

the individual’s relationship to the applicant; and

responsibility for the applicant’s care.

If an applicant makes an "X" on the signature line for applicant/recipient, a witness must sign on the witness signature line.