County of San Diego Health and Human Services Agency HHSA County Medical Services CMS Program Guide Statement of Facts SOF Number Page 0202 1 of 2 Background Workers use the SOF plus appropriate supplemental forms located in the CMS IT System to determine CMS eligibility Policy A Who May Complete and Sign the SOF As long as the applicant has the capacity to discharge hisher responsibilities heshe is responsible for participating in the application process The SOF must be completed and signed as follows If the applicant Then Is competent The SOF must be completed and signed by the applicant or spouse The applicant or spouse is also responsible providing all information and verifications necessary to determine eligibility Is incompetent The SOF must be completed and signed by the applicants in order of rank Spouse Conservator guardian or executor if there is one Relative or person with knowledge of applicants circumstances or Representative of a public agency or the County department Is incapable of signing because of a physical condition Applicant should provide the information and a relative knowledgeable person or worker can sign the SOF Can sign making a mark A witness should also sign the SOF B Authorized Representative AR Applicantsbeneficiaries may designate any person they choose at any time to be an AR to accompany and assist them in the eligibility determination process The AR may not appear or act in lieu of the applicantbeneficiary A competent applicantsbeneficiaries participation in the CMS application process is not excused by designating another person To designate an AR to assist in the application or redetermination process the applicantbeneficiary must sign and date an Appointment of Representative form or any other written authorization The written designation appoints an individual or an individual designated by an organization to assist them in establishing CMS eligibility The AR may assist the applicant at the interview help in obtaining required verification etc The person may be a family member friend representative of an organization or anyone else the applicant chooses While the County must allow applicants the right to choose someone to accompany assist and represent them applicants continue to have the responsibility to cooperate by completing and signing the SOF When there is a facetoface interview the applicant must be present and personally ensure timely and complete responses to requests for information County of San Diego Health and Human Services Agency HHSA County Medical Services CMS Program Guide Statement of Facts SOF Number Page 0202 2 of 2 Any written authorization is required to be signed and dated by the applicantbeneficiary for all CMS cases even when an AR is designated to assist the client in the CMS application or redetermination process The AR authorization does not grant the AR the authority to complete the SOF or attend a facetoface interview in lieu of the applicantbeneficiary Also the authorization does not grant the AR the authority to process ongoing case management or to access the applicantsbeneficiarys other programs The applicantbeneficiary is to understand that if the AR fails to perform as the applicantbeneficiary intends and the application is denied or benefits are discontinued due to that failure the applicantbeneficiary must accept the consequences of the ARs actions or inactions A written AR authorization is to be recognized for one year from the date signed and may be revoked by the applicant at any time C Determining A Knowledgeable Person A knowledgeable Person must have real personal and specific knowledge of the applicants affairs The person must be able to answer vital income and property questions with a response other than unknown When the SOF is completed and signed by someone other than the applicant or hisher spouse that person assumes the responsibilities of the applicant and is liable for declarations made on behalf of the applicant therefore if the person signing the SOF willfully conceals or fails to report essential facts that person not the applicantbeneficiary could be referred for a fraud investigation If the knowledgeable person is found to have no real personal and specific knowledge of the applicants affairs the worker will determine whether another knowledgeable person such as a relative or an LTC representative if the applicant is in LTC is available If no such person is available the worker may sign and complete the SOF Other Program Impact None References None Sunset Date This policy will be reviewed for continuance by 04302019 Release Date April 04 2016