This Rider to the EOHHS Virtual Gateway Services Agreement is entered into by and between the Commonwealth of Massachusetts, Executive Office of Health and Human Services (“EOHHS”) and the undersigned organizational user of the EOHHS Virtual Gateway Services (the “User”).  

This Rider is to be signed by all Users who have been given authorization by EOHHS to use the Common Intake Service of the Virtual Gateway. 

The Common Intake Service of the Virtual Gateway permits an authorized User to conduct, with the permission of an applicant, exchanges of referral, enrollment and/or eligibility information with EOHHS and/or one or more of its agencies in electronic form.  Both parties acknowledge and agree that the privacy and security of applicant personal and financial information held by or exchanged between them is of the utmost importance.  Each party agrees to take all steps reasonably necessary to ensure that the data exchanges between them conform to the privacy and security laws applicable to each party.

User agrees that it shall not use the Common Intake Service to submit an application for MassHealth benefits unless the applicant chooses to grant MassHealth permission to disclose eligibility information to User by executing a Permission to Share Information (PSI) form or chooses to appoint User as a MassHealth eligibility representative by executing an Eligibility Representative Designation (ERD) form. If the applicant does not wish to execute a PSI or ERD, User may not enter application information into the Virtual Gateway, and instead must provide the applicant with a paper MassHealth application packet.  In no event may User require the applicant to complete either the ERD or the PSI form; nor may User complete such forms without the applicant's signature or the signature of someone with legal authority to sign for the applicant.  EOHHS may lift this restriction by written notice to User. 

User (by an authorized representative)			

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Print User Name (Legal Entity Name)		Print Authorized Representative Name	

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User FIN (Tax ID)					Print Authorized Representative Title

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Signature						Date