Ard form 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section I, Part A, enter your name, date of birth, and MassHealth ID number or last four digits of your SSN. Provide your email address and sign to certify your choice of authorized representative.
3. In Part B, the authorized representative must fill in their details including name, phone number, and address. They should also sign to confirm their commitment to confidentiality.
4. If you cannot designate an authorized representative in writing, complete Section II with the necessary information about the applicant/member and the representative's details.
5. For legal representatives, complete Section III by providing relevant legal documentation along with the form.
6. Review all sections for accuracy before submitting. You can submit via mail or fax as instructed at the end of the form.

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