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SECTION

Authorized Representative Designation

(if applicant or member is able to sign)

Part A—to be filled out by applicant or member. Please print, except for signature.

Please note: Your social security number (SSN) is required if one has been issued.

Applicant’s/Member’s Name

SSN (if you have one)

Date of birth (mm/dd/yyyy)

Applicant’s/Member’s e-mail address

I certify that I have chosen the following person or organization to be the authorized representative for myself and any dependent

children under the age of 18 for whom I am the custodial parent and that I understand the duties and responsibilities this person or

organization will have (as explained earlier in this form).

Applicant’s/Member's signature

Date

Authorized representative’s name

Authorized representative’s phone number

Authorized representative’s address (mailing address, city, state, zip)

Part B—to be filled out by authorized representative. Please print, except for signature.

B1. COMPLETE IF AUTHORIZED REPRESENTATIVE IS A PERSON.

I certify that I will at all times maintain the confidentiality of any information regarding the applicant or member set forth above and,

if applicable, the dependent children of such applicant or member, that is provided to me by MassHealth or the Health Connector.

If I am also a provider, staff member, or volunteer affiliated with an organization, and am acting in my capacity as a provider, staff

member, or volunteer in connection with my designation as an authorized representative, I certify that I will at all times adhere

to all applicable state and federal laws and regulations regarding confidentiality of information and conflicts of interest including

those set forth at 42 C.F.R. part 431, subpart F, 42 C.F.R. § 447.10, and 45 C.F.R. § 155.260(f).

Authorized representative’s signature

Date

Authorized representative’s printed name

Authorized representative’s e-mail address

B2. COMPLETE IF AUTHORIZED REPRESENTATIVE IS AN ORGANIZATION.

I certify, on behalf of the organization set forth below, that such organization will at all times maintain the confidentiality of any

information regarding the applicant or member set forth above and, if applicable, the dependent children of such applicant or

member, that is provided to the organization by MassHealth or the Health Connector.

I, the provider, staff member, or volunteer of the organization set forth below, completing this form, certify on behalf of myself

and on behalf of the organization I represent, that any providers, staff members, or volunteers acting on behalf of the organization

in connection with this authorized representative designation will at all times adhere to all applicable state and federal laws and

regulations regarding confidentiality of information, and conflicts of interest, including those set forth at 42 C.F.R. part 431, subpart

F, 42 C.F.R. § 447.10, and 45 C.F.R. § 155.260(f).

Signature of provider, staff member, or volunteer completing form

Date

Printed name of provider, staff member, or volunteer completing form

E-mail of provider, staff member, or volunteer completing form

Authorized representative organization name

Page

ARD (Rev. 03/15)

Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 31

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