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Get MA Application for Waiver or Reduction of MassHealth Premium 2009-2024

In filling out this form, you must be active on our computer system as a MassHealth Eligibility Representative (ERD). If you are not, you must fill out an ERD form and send it back with this application. Your signature or the signature of your eligibility representative on this application certifies that the information on this form is correct and complete to the best of your knowledge. X Signature of member Date X Signature of eligibility representative Date .

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