Get Authorized Representative Designation Form - Massachusetts ...

Completing the Authorized Representative Designation Form online is a crucial step in designating an individual to help manage your health care coverage. This guide provides clear instructions to ensure a smooth and accurate submission.

Follow the steps to successfully fill out the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section I, Part A, provide your name and social security number if applicable. Fill in your date of birth and email address. Sign and date the form to certify your choice of an authorized representative.
3. In Part B, your chosen authorized representative must complete the required fields, including their name, address, phone number, and date of birth. They must also sign and date the form, confirming their understanding of confidentiality requirements.
4. If the designated representative is an organization, they must complete Section B2, including the printed name of the organization and the signature of the representative completing the form.
5. For individuals unable to provide written designation, complete Section II with the authorized representative’s information, confirming they can take responsibility on your behalf.
6. If applicable, the representative appointed by law must fill out Section III and provide the legal document that validates their appointment.
7. Once all sections are completed accurately, save any changes made to the form. You can then choose to download, print, or share it as needed, ensuring to submit it as directed in your application process.

Start filling out your Authorized Representative Designation Form online today for efficient management of your health care coverage.