Enrollment Assister Forms

Enrollment Assister Forms 2017-09-13T16:31:14+00:00

About Enrollment Assister Authorization Forms

In order to authorize your certified Enrollment Assister to help you complete your application, both of you will need to complete the authorization form and submit it to the address or fax number listed on the form. Different certified Enrollment Assister types will have a different type of form.

The types of certified Enrollment Assisters are

  • Navigators who use a Navigator Designation Form
  • Certified Application Counselors, who use a Certified Application Counselor (CAC) Designation Form
  • Issuer Enrollment Assisters who use an Issuer Application Assister Disclosure Form

You will get one of these forms to fill out when you meet with an Enrollment Assister.

 

Getting help from someone who is not a certified Enrollment Assister?

If you are apply with the help of a family member, friend, or other trusted person, you will both need to complete an Authorized Representative Designation (ARD) Form. You can submit this form if you would like to designate an authorized representative to act on your behalf.

If an authorized representative signed your application for you, or if you are an authorized representative applying on behalf of someone else, you MUST submit this form for the application to be processed.

You do not need to fill out this form if you live in an institution and want copies of eligibility notices sent to you and to your spouse who still lives at home. MassHealth and the Health Connector will do that automatically.

NOTE: An authorized representative has the authority to act on an applicant’s or member’s behalf in all matters with MassHealth and the Health Connector, and will receive personal information about the applicant or member until we receive a cancellation notice terminating their authority. Their authority will not automatically terminate once we process your application.

Who can help me?

  1. 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. You must designate in writing (fill out Section I, Part A) the person or organization who you want to be your authorized representative. Your authorized representative must also fill out Section I, Part B of the ARD form.
  2. If, because of a mental or physical condition, you cannot designate an authorized representative in writing, a person (not an organization) who is acting responsibly on your behalf can be your authorized representative if that person certifies, by filling out Section II of the ARD form, that you are not able to provide a written designation, and that he or she is acting responsibly on your behalf.
  3. An authorized representative can also be someone who has been appointed by law to act on your behalf. This person must fill out Section III of the ARD form and either you or this person must submit to us, together with this form, a copy of the applicable legal document stating that this person is lawfully representing you.
  4. A person appointed by law to act on behalf of the estate of an applicant or member who has died can also serve as an authorized representative by following the instructions above. An authorized representative under Section III of the ARD form may be a legal guardian, conservator, holder of power of attorney, or health care proxy, or, if the applicant or member has died, the estate’s administrator or executor. What this person is authorized to do for you or for the applicant or member’s estate will depend on the wording of the legal appointment.

What can an authorized representative do?

An authorized representative may

  • fill out your application or eligibility review forms;
  • fill out other MassHealth or Health Connector eligibility or enrollment forms;
  • give proof of information reported on these forms;
  • report changes in income, address, or other circumstances;
  • get copies of all of your MassHealth and Health Connector eligibility and enrollment notices; and
  • act on your behalf in all other matters with MassHealth and the Health Connector.