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Masshealth authorized representative form

Masshealth authorized representative form 2025

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The document is an application form for Independent Medical Review (IMR) provided by the State of California's Division of Workers' Compensation. It outlines the process for employees to request a review of medical treatment decisions made by claims administrators that deny, delay, or modify requests from treating physicians. The form requires detailed information about the employee, medical provider, and requested treatment, along with consent for obtaining medical records. Instructions are included on how to complete and submit the application, as well as information on employee rights and eligibility for IMR.

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Click ‘Get Form’ to open the masshealth authorized representative form in the editor.
Begin by filling out the Employee Information section. Enter your first name, middle initial, last name, claim number, date of injury, and date of UR decision. Ensure all details are accurate.
Next, complete the Medical Provider Information section with the provider's first and last name.
In the Claims Administrator Information section, provide your employer's name, claims administrator company name, contact name, address, and phone number.
Fill in the Requested Medical Treatment section by indicating your primary diagnosis and detailing the treatment requested. Attach additional pages if necessary.
Sign and date where indicated to request an independent medical review. Review and sign the consent to obtain medical records.
Finally, ensure you have attached a copy of the utilization review decision before submitting your application.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the authorized representative designation for MassHealth?

Authorized Representative Designation Form [ARD (11/22)] This form is used to designate an authorized representative who can help the applicant or member with the responsibilities of applying for or getting MassHealth.

How to become an authorized representative for Medicaid?

To name you as an Authorized Representative, your loved one must complete a form called the Medicare Authorization to Disclose Personal Health Information. If your loved one is unable to complete the form, you may do it as long as you have legal documentation giving you that right.

What makes someone an authorized representative?

An Authorized Representative is an individual with legal authority to bind the government entity (e.g., the Chief Executive Officer of the government entity).

How do I become an authorized representative for Medicaid?

You can fax your MassHealth Health Plan Enrollment Form to (617) 988-8903.

What is an authorized patient representative?

An Authorized Representative is someone you can name and give access to your Protected Health Information (PHI). An Authorized Representative can be family members, friends, or any other individual you choose.

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Can I be an authorized representative?

An authorized representative can be any member of the general public (see exception regarding employees below), personnel officer, foreman, agent, or notary public where permissible.