Page 51

• Obtains a copy of the patient’s representative’s Patient’s Representative Declaration F- 03436 indicating that they have the authority to act on behalf of the incapacitated individual • Reviews the document to confirm the authority has not ended due to a change in circumstances The application is not properly signed unless both conditions are met.

A patient’s representative may not authorize expenditures related to health care if the incapacitated individual has an agent under a durable power of attorney for finances who may authorize expenditures related to health care. See #4, above. 2.5.2 Witnessing the Signature The signatures of two witnesses are required when the application is signed with a mark. An agency staff person is not required to witness the signature of a paper, online, or telephonic application. Note This does not affect the state of Wisconsin’s ability to prosecute for fraud due to an applicant's or member’s misstatement or omission of fact. 2.5.3 Spousal Impoverishment Medicaid Signatures All spousal impoverishment Medicaid applications, renewals, or changes in marital status that cause someone to be subject to spousal impoverishment rules, require the signatures of both the institutionalized person and the community spouse or of a person authorized to sign for them as described in SECTION 2.5.1.1 SIGNATURES FROM REPRESENTATIVES. If the benefits are denied or terminated because the community spouse refuses to sign, disclose the value of assets, or provide required information on income or resources, the applicant or member must be sent information on the Undue Hardship Waiver process. For more information on this policy, see SECTION 22.4 UNDUE HARDSHIP and Process Help Section 12.18.6 Undue Hardship. 2.5.4 Telephone Signature Requirements Telephonic signatures are valid forms of signatures for Medicaid. When an applicant calls to complete a Request for Assistance (RFA) but does not complete a full application on the same day, a telephonic signature must be collected for the RFA. Another telephonic signature will be required when the full application is completed. However, if the RFA and full application are completed on the same day, a telephonic signature only has to be collected once, and it is valid for both the RFA and the application. 2.5.5 Valid Signature on the Federally-Facilitated Marketplace Application The signature on the FFM application is accepted for all individuals on that application. There may be a need to create companion cases for adult children listed on a FFM application, without obtaining a separate signature or application. This policy is for FFM applications only. Current policies for non-FFM applications requiring an adult child to apply separately are still valid.