1. (a) A individual who chooses an authorized representative (AR), as defined in He-W 601.01(w), to help with some or all the responsibilities of applying for or receiving medical assistance shall provide all of the following information in writing:

   1. (1) The name, address, and telephone number of the AR;
   2. (2) The duties that the AR will carry out, as specified in (c) below;
   3. (3) The individual's relationship to the AR;

   4. (4) A statement signed and dated by the individual acknowledging:

      1. a. His or her responsibility for any errors, omissions, failures to report information to DHHS, or inaccurate information reported to DHHS by the AR;
      2. b. That if the AR uses the individual’s benefits without permission, these benefits will not be replaced by DHHS;
      3. c. That the person the individual names as the AR will continue to act for the individual until the individual or the AR tells DHHS of a change; and
      4. d. Comprehension of the individual’s choice of AR and the duties assigned to that AR; and

   5. (5) A statement signed and dated by the AR:

      1. a. Agreeing to accept the responsibilities designated by the individual;

      2. b. Acknowledging that the AR understands that:

         1. 1. Proof of the AR’s identity is required;
         2. 2. If disqualified for a program violation, the person identified as the AR can no longer act as an AR unless there is no one else suitable to represent the individual; and
         3. 3. The AR will continue to act as an AR for the individual until the AR or the individual tells DHHS of a change.

2. (b) To qualify as an AR, an individual shall be an adult who has:

   1. (1) Expressed concern for the individual's wellbeing;
   2. (2) Sufficient knowledge about the individual's circumstances to assist the individual in applying for or receiving assistance; and
   3. (3) The capability to obtain information about the individual's circumstances.

3. (c) The individual may authorize an AR to carry out one or more of the following responsibilities:

   1. (1) Obtaining DHHS applications and other forms or DHHS paperwork, and completing these for the individual;
   2. (2) Attending eligibility interviews for the individual;
   3. (3) Providing DHHS with verification of the individual's income, resources and other case circumstances;
   4. (4) Reporting and verifying changes in the individual's case circumstances to DHHS;
   5. (5) Receiving the individual's medical assistance identification card and other DHHS mail;
   6. (6) Asking for, attending, and representing the individual at administrative appeals for the individual;
   7. (7) Communicating with the individual’s managed care organization or qualified health plan; and
   8. (8) Any other duties regarding eligibility for medical assistance an individual chooses to designate to an AR.

4. (d) If designated pursuant to (a)(2) above, ARs shall:

   1. (1) Sign DHHS forms completed on behalf of the individual; and
   2. (2) Co-sign DHHS forms they assist the individual in completing.

Source. #11042, eff 2-24-16