Form YY "Authorized Representative Form - Mnsure" - Minnesota

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Giving Permission for Someone to Act on My Behalf
Someone with permission to act on your behalf is called an authorized representative. This person will
have the same responsibilities as you regarding your eligibility and enrollment through MNsure. He or
she will receive forms, notices and premium notices on your behalf and can report any application
changes or updates.
What do I need to do to give this permission?
Read the information in this document carefully. If you wish to give someone permission to act on your
behalf, complete Part 1 of the form yourself. Then your authorized representative needs to complete
Part 2 of the form. Both you and this person must sign and date this form.
Mail the form to:
MNsure Operations
PO Box 64253
St. Paul, MN 55164-0253
Or fax the form to 651-431-7770.
If you have questions, call the MNsure Contact Center at 855-366-7873.
(form is on next page)
MNsure Form YY 05/17
Page 1 of 3
Giving Permission for Someone to Act on My Behalf
Someone with permission to act on your behalf is called an authorized representative. This person will
have the same responsibilities as you regarding your eligibility and enrollment through MNsure. He or
she will receive forms, notices and premium notices on your behalf and can report any application
changes or updates.
What do I need to do to give this permission?
Read the information in this document carefully. If you wish to give someone permission to act on your
behalf, complete Part 1 of the form yourself. Then your authorized representative needs to complete
Part 2 of the form. Both you and this person must sign and date this form.
Mail the form to:
MNsure Operations
PO Box 64253
St. Paul, MN 55164-0253
Or fax the form to 651-431-7770.
If you have questions, call the MNsure Contact Center at 855-366-7873.
(form is on next page)
MNsure Form YY 05/17
Page 1 of 3
Part 1: I want to give permission for someone to act as my authorized representative.
I understand the following:
My authorized representative must be at least 18 years old and know my circumstances in order
to provide necessary information about me.
My authorized representative will be authorized to access eligibility and enrollment information
about me so they can make informed decisions for me.
Although the information about me is considered private at MNsure, MNsure cannot control how
the information is shared by my authorized representative.
My authorized representative can help me fill out forms, give information about me, and must
report changes that may affect my eligibility and enrollment through MNsure.
My authorized representative can act for me until I no longer want him or her to. I must tell
MNsure if I no longer want this individual to act on my behalf.
I am being asked to provide the information below to allow MNsure to verify my identity. If I do
not provide this information, I will not have an authorized representative.
MNsure employees and others with legal authority will have access to this data. This information
may be kept for up to ten years.
I give permission to
to act for me.
(PRINT THE FIRST AND LAST NAME OF THE PERSON ACTING ON YOUR BEHALF)
(print)
SIGNATURE
DATE
YOUR NAME
YOUR STREET ADDRESS
CITY
STATE
ZIP CODE
YOUR PHONE NUMBER
Part 2: I want to act as someone’s authorized representative.
I understand the following:
I will have the same responsibilities as the individual above regarding his or her eligibility and
enrollment through MNsure, including a responsibility to report any application or enrollment
changes.
As a result of these responsibilities, I will have access to MNsure’s private information about this
individual. I must treat the information according to the laws and policies that apply to me as an
authorized representative.
As an authorized representative, I will have the power to complete and submit an application for
the individual above; report application or enrollment changes; receive copies of his or her
eligibility notices or other communications from MNsure; and generally act on his or her behalf
with MNsure.
I am required to follow applicable state and federal laws concerning conflicts of interest.
I must notify MNsure and the individual above if I no longer have the authority to act as an
authorized representative.
I am being asked to provide the information below to allow MNsure to verify my identity and
contact me if needed. If I do not provide this information, I will not be an authorized
representative. MNsure employees and others with legal authority will have access to this data.
This information may be kept for up to ten years.
SIGNATURE OF PERSON ACTING ON YOUR BEHALF
DATE
HIS/HER PHONE NUMBER
HIS/HER STREET ADDRESS
CITY
STATE
ZIP CODE
MNsure Form YY 05/17
Page 2 of 3
For accessible formats of this publication or assistance with additional equal access to human
services, write to AEO@MNsure.org, call 855-366-7873 (MNsure Contact Center) or use your
preferred relay service.
(ADA1 [9-15])
MNsure Form YY 05/17
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