Citizen 6765 Bedienungsanleitung PDF herunterladen (Seite 7)

Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765)

TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.

Questions?

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Appendix A

Get help completing this application.

You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and

act for you on matters related to this application, including getting information about your application and

signing your application on your behalf. This person is called an “authorized representative.” If you would

like to have an authorized representative, download the Authorized Representative Designation (ARD) Form

from our website at MAhealthconnector.org or call Customer Service at 1-877-MA ENROLL.

For Certied Application Counselors, Navigators, and Brokers only

Complete this section if you’re lling out this application for somebody else. Navigators must ll out a

Navigator Designation Form if you have not done so already. Brokers and Certied Application Counselors,

please ll out a separate ARD/PSI Form if you do not already have one on le with the Health Connector.

Date (month/day/year)

First name Middle name Last name Sufx

Organization name

STEP 5

Mail completed application.

 Mail your signed application to:

Massachusetts Health Connector

133 Portland Street, 1st Floor

Boston, MA 02114-1707

FAX: (877) 623-2155

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Citizen 6765 Bedienungsanleitung Seite 7