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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 January 2003 Subchapter Subject

Page M0120 MEDICAL ASSISTANCE APPLICATION Appendix 1 1

Commonwealth of Virginia Department of Social Services

NOTICE REGARDING MEDICAID APPLICATION REQUIREMENTS

A Medicaid application has been filed on the behalf of __________________________________ (name of applicant). However, the application is not valid and cannot be processed because the application must be signed by one of the following persons:

• the parent of a person under age 18,

• the adult who is the legal guardian or has legal custody of a person under age 18,

• any adult related by blood or marriage with whom a person under age 18 lives,

• the person for whom Medicaid is requested if the person is over age 18 or an emancipated minor,

• the authorized representative for the person who is requesting assistance, who may be

- any person to whom he/she has legally given power of attorney, or

- any person who he/she has designated by a signed written statement to apply on his/her behalf for Medicaid or public benefits, or

• the guardian, conservator, or committee of a person over age 18 who has been judged legally incapacitated by a court of law.

Please return the signed application and the authorized representative statement (if needed) by ______________________________ so that the application may be processed. Thank you. (date)

_________________________________________ _________________________ Signature

Date

_________________________________________ Title

_________________________________________ Agency Name

______________________________________ Phone Number