Minnesota Administrative Rules

9050.0900 AUTHORIZATION FORMS.

Subpart 1.

Required.

An applicant or resident, spouse, or legal representative, if any, shall provide a separate signed authorization form for each verification that must be obtained from a third party.

Subp. 2.

Content.

The authorization form must contain the following information above the person's signature:

A.

person's name;

B.

date;

C.

information authorized;

D.

who is authorized to give the information;

E.

to whom the information is to be given;

F.

information's use; and

G.

date of expiration of the authorization.

A separate form must be signed and completed for each authorization of access. The period of the authorization must not exceed one year.

Subp. 3.

Refusal to sign authorization forms; consequences.

Failure to complete and sign authorization forms on or by the day of admission must result in the resident being refused admission to the facility. The applicant or resident, applicant's or resident's legal representative, or spouse must complete the following tasks within 30 days of the financial interview or other authorized request:

A.

complete and sign a financial information or authorization form;

B.

apply for insurance or other benefits for which an applicant, resident, or spouse of an applicant or resident may be eligible;

C.

complete assignment of benefits forms required by third-party payers;

D.

sign authorizations for release of medical records; and

E.

provide verification of information given on financial disclosure forms.

Providing false information relating to items A to E results in disqualification of an application for admission or in discharge of a resident under part 9050.0200, subpart 3, item E. The maintenance charge must be redetermined or the application for admission must be reinstated or the discharge proceeding discontinued if the applicant, resident, or spouse takes the required action.

Statutory Authority:

MS s 198.003

History:

14 SR 2355; 28 SR 1251

Published Electronically:

October 15, 2008