Health Care Program Participant Application and Certification Process

Each Health Care Program Participant must be certified by the Program Manager to participate in the Program. (2) Health Care Program Participant certification will be granted only where the prospective Health Care Program Participant: (a) is a current Massachusetts resident; (b) is an individual engaged in the provision, facilitation or promotion of a legally-protected health care activity; (c) provides specific evidence that the applicant is engaged in the provision, facilitation or promotion of a legally-protected health care activity or the applicant provides other specific evidence deemed acceptable in the sole discretion of the Program Manager and General Counsel of the Office of the Secretary of the Commonwealth. (d) completes, signs, dates and provides all necessary information required under M.G.L. c. 9A, § 2 and the standard application form provided by the Program; (e) agrees in writing to use the applicable substitute addresses designated by the Program for use by Health Care Program Participants; (f) agrees in writing to abide by 950 CMR 131.00 and all other written Program rules, policies and procedures; (g) provides the residential address and mailing address, if applicable, where the applicant may be contacted by the Program Manager or their designee and the telephone number(s) where the applicant may be called by the Program Manager or their designee; and (h) provides one or more addresses the applicant requests not be disclosed for the reason that disclosure will jeopardize the applicant's safety or increase the risk of violence to the applicant or members of the applicant's household. (i) demonstrates custody or guardianship of any minor children or incapacitated persons also being admitted to the Program and agrees not to use the Program to evade law enforcement or to avoid establishing or following child custody or visitation orders. (3) Prior to certification of the application, the Secretary of the Commonwealth may request additional documentation from the Program applicant. A properly completed application shall be effective on the day that it is certified by the Program Manager. An individual who is certified as a Health Care Program Participant shall be issued an identification card which includes their name, identification code, substitute address, certification expiration date, and applicant's signature. (6) The term of a Health Care Program Participant's certification shall be four years following the effective date of their certification unless the certification is withdrawn or canceled before that date pursuant to M.G.L. c. 9A, § 3 or 950 CMR 131.08.