Exact text from comm_care_application.pdf - Page 7 from MBR dated 2007

Please read this page carefully, then sign and date the bottom of the page. 
This is an application for MassHealth, the Children’s Medical Security Plan (CMSP), Healthy Start, Commonwealth Care, and the Uncompensated Care Pool. 

I give permission for my current and former employers and health insurers to release to MassHealth any and all information they have about my health-insurance coverage and health-insurance coverage for members of my family group. This includes, but is not limited to, information about policies, premiums, coinsurance, deductibles, and covered benefits that are, may be, or should have been available to me or members of my family group. 
 
I and my spouse understand that our employers may be notified and billed, in accordance with the regulations of the Division of Health Care Finance and Policy, with regard to any services I and my spouse and any of our dependents may get from hospitals or community health centers that are paid for by the Uncompensated Care Pool. 

I give permission to MassHealth to get any records or data to prove any information given on this application and any supplements to it, or other information I give to MassHealth once I am a member. If I or my family is found eligible for MassHealth, CMSP, or Healthy Start, I give permission to MassHealth to get any records about medical services provided through these programs. If I or any family member is found eligible for Commonwealth Care, I give permission to the Commonwealth Health Insurance Connector Authority (“the Connector”) to get any records about medical services provided through that program. 

I understand that if I am aged 55 or older, after I die, MassHealth may be able to get back money from my estate. 

I understand that if I or any members of my family are in an accident, or are injured in some other way, and get money from a third party because of that accident or injury, we will need to use that money to repay MassHealth for certain medical services provided, as explained in the MassHealth Member Booklet. I also understand that I must tell MassHealth in writing, within 10 days, if I file any insurance claim or lawsuit because of an accident or injury to me or a family member applying for benefi ts.
  
I understand that if I or any members of my family are members of Commonwealth Care and we are in an accident, or injured in some other way, and get money from a third party because of that accident or injury, we may need to use that money to repay the Connector or my current health insurer for certain medical services provided, as explained in the MassHealth Member Booklet. I also understand that I must tell my health insurer in writing, within 10 days, if I file any insurance claim or lawsuit seeking benefits because of an accident or injury. 
 
I understand that if I or any members of my family are eligible for MassHealth, CMSP, Healthy Start, Commonwealth Care, or the Uncompensated Care Pool, I must tell MassHealth of any changes in my or my family’s income or employment, family size, health-insurance coverage, health-insurance premiums, and immigration status, or of changes in any other information I gave on this application and any supplements to it within 10 days of learning of the change.
 
I also understand that by signing below, I give permission to MassHealth to go after and collect third-party payments for medical care and medical support from the parent of any child under age 19 who is applying for benefi ts. 

If I or any member of my family is eligible for MassHealth or CMSP, I understand that I may have to pay a premium set by MassHealth. If I am a certain American Indian or Alaska Native eligible for MassHealth Family Assistance, I may not have to pay any premiums under MassHealth Family Assistance. If I or any member of my family is eligible for Commonwealth Care, I understand that I may have to pay a premium set by the Connector. 
 
By signing this application, I am also certifying the identity of my children or the children that I am the legal guardian of who are under age 16 and do not have acceptable proof of identity. I know of my own personal knowledge the place and date of birth of the children identified on this application. I also understand that this application is acknowledged as an affidavit of identity for my children under age 16, and that this information is sworn under penalty of perjury. 
 
I certify that I have read or had read to me the information on this application and on any supplements to it and the information in the MassHealth Member Booklet, and that I understand my rights and responsibilities. I further certify under the penalty of perjury that the information on this application and any supplements to it is correct and complete to the best of my knowledge. 
 
If you are acting on behalf of someone in filling out this application and any supplements to it, the enclosed MassHealth Eligibility Representative Designation Form must also be filled out and sent back with this application. Your signature on this application as an eligibility representative certifi es hat the information on this application and any supplements to it is correct and complete to the best of your knowledge. 
 
If you think MassHealth’s decision about whether you are eligible is wrong, you have the right to appeal or file a grievance. If you are denied benefits, you will get information about how to appeal or file a grievance.

The head of household, all persons aged 18 or older, and all parents of any age who have children living with them who are applying for MassHealth, CMSP, Healthy Start, Commonwealth Care, or the Uncompensated Care Pool, must read this page carefully, and sign and date below. If you are signing below as an eligibility representative, a filled-out MassHealth Eligibility Representative Designation Form must also be submitted.
 
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