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MassHealth Authorized Representative Designation Form [ARD (11/22)] A form used to designate an authorized representative who can help the applicant or member with the responsibilities of applying for or getting MassHealth.
An authorized representative can be a friend, family member, relative, or other person or organization of your choosing who agrees to help you. It is up to you to choose an authorized representative if you want one. Neither MassHealth nor the Health Connector will choose an authorized representative for you.
Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.
Contact Center hours are 9 a.m. ? 4 p.m., Monday through Friday. (617) 887-6367 or (800) 392-6089 (toll-free in Massachusetts).
(Failure to complete this form in its entirety will invalidate this authorization) An Authorized Representative is a person you authorize to act on your behalf, in pursuing a claim or an appeal of a denied claim.
What you need Social Security numbers, if you have them, for every household member who is applying. Proof of income and assets. Proof of any health insurance that you are currently enrolled in or have access to. Information about or proof of citizenship/national status or immigration status.
Contact Us For all departments (857) 368-4636. Toll Free (877) 623-6846. TTY (857) 368-0655.