Get Ma Ard-1122 2022-2025

The MA ARD-1122 is the Authorized Representative Designation Form, which allows you to designate a representative to act on your behalf in matters related to health care coverage. This guide provides step-by-step instructions on how to complete this form online, ensuring a smooth and effective process.

Follow the steps to fill out the MA ARD-1122 correctly.

1. Press the ‘Get Form’ button to access the MA ARD-1122 form and open it in the editor.
2. In Section 1, Part A, fill in the applicant's or member's name, date of birth, MassHealth ID number or last four digits of their SSN, and email address. Ensure to print clearly except for the signature.
3. In Part A, the applicant or member must provide their signature and the date of signing, confirming that they choose the authorized representative listed.
4. In the same section, fill in the authorized representative's name, phone number, and mailing address accurately.
5. Proceed to Part B, and depending on whether the authorized representative is a person or an organization, fill out the corresponding fields. This includes certifying confidentiality and signing the form.
6. If the authorized representative is a person, ensure they sign and date the form, while providing their printed name and email address.
7. If the representative is an organization, an authorized individual from that organization must sign and provide their title and date of signing.
8. If needed, move to Section 2 to designate an authorized representative when the applicant cannot provide written designation. Fill out all applicable fields accurately.
9. In Section 3, if applicable, fill out the details for a representative appointed by law, ensuring to include a copy of the legal document with the form.
10. Review all entered information for accuracy and completeness before submitting the document.
11. After completing the form, you can save changes, download, print, or share the form as necessary.

Complete the MA ARD-1122 online today for a smoother health coverage application process.