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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 October 2018 Subchapter Subject Page ending with Page M0120 MEDICAL ASSISTANCE APPLICATION M0120.200 4

3. Procedure for Who Can Sign the Application When preparing to determine the MA eligibility of an individual age 18 or older, examine the application to determine if the applicant can complete and sign the application form or if the applicant has an authorized representative. Ask the following questions: Has the applicant been judged legally incapacitated by a court of law, as evidenced by a copy of the conservator or guardian certificate of appointment in the record? YES:

The authorized representative is the appointed conservator or guardian. STOP. NO:

The applicant is competent. Does the applicant have an attorney in fact who has the power of attorney to apply for MA for the applicant as evidenced by a copy of the power of attorney document in the record?

YES: The authorized representative is the attorney in fact. STOP.

NO: Has the applicant signed a written statement authorizing a person (or staff of an organization) to apply for MA on his behalf? (Note: a completed authorized representative section on a telephonic application is acceptable)

YES: The authorized representative is the person or organization authorized by the applicant to represent him. STOP.

NO: Is the applicant able to sign or make a mark on a Medicaid application form?

YES: Ask the applicant for his signature or mark on the application form or for a written statement authorizing someone to apply for MA on his behalf. Give the applicant 10 working days to return the completed and signed form(s). If the completed and correctly signed form(s) are not returned by the specified date, DENY MA because of an invalid application.