Page 1 begins. MassHealth Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth Health Connector Commonwealth Care Eligibility Representative Designation Form What an eligibility representative does You may choose an eligibility representative to help you with some or all of the responsibilities of applying for or getting health benefits (MassHealth, Commonwealth Care, the Children’s Medical Security Plan, Healthy Start, and the Health Safety Net). You can do this by filling out this form (the MassHealth Eligibility Representative Designation Form (ERD)). The person you choose must know enough about you to take responsibility for the correctness of the statements made during the eligibility process. An eligibility representative may fill out your application or eligibility review form and other MassHealth eligibility forms, give proof of information given on these eligibility forms, report changes in your income, address, or other circumstances, and get copies of all MassHealth eligibility notices sent to you. Under MassHealth regulations 130 CMR 516.007, MassHealth is allowed to send a copy of all applicant and member eligibility notices to the applicant’s or member’s institution where he or she is living, and to his or her spouse who is living at home, without an ERD being filled out. Who can be an eligibility representative An eligibility representative can be a friend, family member, relative, or other person who has a concern for your well-being and who agrees to help you. An eligibility representative is a person you choose. MassHealth will not choose an eligibility representative for you. You must designate in writing on this form (please fill out Section I, Part A) the person you want to be your eligibility representative. Your eligibility representative must also fill out Section I, Part B. If, because of a mental or physical condition, you cannot designate in writing an eligibility representative, a person who is acting responsibly on your behalf can be your eligibility representative if that person certifies, by filling out Section II, that you are not able to provide a written designation, and that he or she is acting responsibly on your behalf. An eligibility representative can also be someone who has been appointed by law to act on your behalf or on behalf of your estate. This person must fill out Section III, and either you or this person must submit to MassHealth a copy of the applicable legal document stating that this person is lawfully representing you or your estate. This person 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. Depending on the wording of the legal appointment, this person may be able to help you or get information for you in other matters that do not apply only to your eligibility. Please Note: The applicant’s or member’s social security number (SSN) is required if one has been issued, unless he or she is applying for or getting only MassHealth Limited, the Children’s Medical Security Plan (CMSP), Healthy Start, or the Health Safety Net. How an eligibility representative designation ends A Section I or II eligibility representative’s designation ends 18 months after the date he or she signs this form. To designate this person again, or to designate another person as your eligibility representative, you must submit a new ERD. A Section III eligibility representative’s designation ends when his or her legal appointment ends. If at some time during the 18-month period you no longer want this person to be your eligibility representative, you must send a letter stating this to: Privacy Office, 600 Washington Street, Boston, MA 02111. Where to send this form If you are applying for health benefits, send your filled-out ERD in with your application. If you are already getting health benefits, send your filled-out ERD to MassHealth Enrollment Center P.O. Box 1231 Taunton, MA 02780 Page 2 begins. SECTION I: Eligibility 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. Applicant/Member name SSN Date of birth I certify that I have chosen the following person to be my eligibility representative, and that I understand the duties and responsibilities this person will have (as explained on the other side of this form). Eligibility representative name Relationship to you Eligibility representative address: street address, city, state, zip Eligibility representative telephone no. Applicant/Member signature Date Part B—to be filled out by eligibility representative I certify that I know enough about the above applicant or member to take responsibility for the correctness of the statements made during the eligibility process, and that I understand my duties and responsibilities as this person’s eligibility representative (as explained on the other side of this form). Eligibility representative signature Date SECTION II: Eligibility Representative Designation (if applicant or member cannot provide written designation) To be filled out by eligibility representative—please print, except for signature. I certify that I know enough about the applicant or member named below to take responsibility for the correctness of the statements made during the eligibility process, that I understand my duties and responsibilities as this person’s eligibility representative (as explained on the other side of this form), and that this person cannot provide written designation. If this person can understand, I have told the person that MassHealth will send me a copy of all MassHealth eligibility notices and this person agrees to this, and I have told this person that he or she may remove or replace me as eligibility representative at any time by sending a letter to: Privacy Office, 600 Washington Street, Boston, MA 02111. Applicant/Member name SSN Date of birth Eligibility representative name Your relationship to applicant or member Eligibility representative address: street address, city, state, zip Eligibility representative telephone no. Eligibility representative signature Date SECTION III: Eligibility Representative Designation (appointed by law) To be filled out by eligibility representative appointed by law (as explained on the other side of this form)—please print, except for signature. Please attach copy of applicable legal document. Applicant/Member name SSN Date of birth Eligibility representative name Eligibility representative address: street address, city, state, zip Eligibility representative telephone no. Eligibility representative signature Date ERD (Rev. 01/13) Document ends.