Applications and Member Forms
Applications and Application-Related Publications
MassHealth Medical Benefit Request [MBR (09/09)]
An application for people who are under age 65 and who are not living in a nursing home or other long-term-care facility.
- MassHealth Medical Benefit Request [English] (PDF) | RTF
- MassHealth Solicitud de beneficios médicos (PDF) | RTF
MassHealth Member Booklet [HCR-2 (09/09)]
A booklet for people who are under age 65 and who are not living in a nursing home or other long-term-care facility.
- MassHealth Member Booklet [English] (PDF 1.12MB) | RTF
- MassHealth Folleto para afiliados (PDF 1.04MB) | RTF
To get this booklet in Cambodian, Chinese, Laotian, Brazilian Portuguese, Russian, or Vietnamese, please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss).
MassHealth Enrollment Guide (11/07)
This guide explains how to choose a health plan and a primary care doctor, and how to enroll in a health plan.
- MassHealth Enrollment Guide [English] (PDF 1.71MB) | RTF
- MassHealth Guía de afiliación (PDF 1.96MB) | RTF
Senior Medical Benefit Request [SMBR (09/09)]
An application for seniors and people needing long-term-care services.
- Senior Medical Benefit Request [English] (PDF) | RTF
- Senior Solicitud de beneficios médicos (PDF) | RTF
MassHealth and You Guide [MH + You Guide (09/09)]
A guide for seniors and for persons of any age needing long-term-care services.
To get this guide in Cambodian, Chinese, Laotian, Brazilian Portuguese, Russian, or Vietnamese, please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss).
U.S. Citizenship/National Status and Identity Requirements for MassHealth [C+I (09/09)]
A form that provides complete information about acceptable proofs of U.S. citizenship/national status and identity.
- U.S. Citizenship/National Status and Identity Requirements for MassHealth [English] (PDF) | TEXT
- Requisitos de identidad y condición de ciudadanía/nacionalidad de los E.E.U.U. para MassHealth (PDF) | TEXT
Long-Term-Care Supplement [LTC-SUPP (08/08)]
A form for persons applying for or already receiving long-term-care services.
- Long-Term-Care Supplement [English] (PDF) | TEXT
- Suplemento para atención a largo plazo (PDF) | RTF
- IRS Form 4506 [10/08] (PDF) | RTF
Personal-Care-Attendant Handbook
Personal-Care-Attendant Supplement [PCA-SUPP (08/08)]
A form for persons who need personal-care-attendant services.
- Personal-Care-Attendant Supplement [English] (PDF) | TEXT
- Suplemento PCA para obtener los servicios de un ayudante de atención individual (PDF) | TEXT
MassHealth Buy-In [MHBI-1 (01/10)]
An application and brochure for people who are eligible for Medicare.
- MassHealth Buy-In for people who are eligible for Medicare [English] (PDF) | RTF
- MassHealth Buy-In para personas que reúnen los requisitos de Medicare (PDF .99MB) | RTF
Fair Hearing Request Form [FHR-1 (02/06)]
A form used by applicants and members who want to ask for a fair hearing.
Insurance Partnership Employer Application [IP-ER-APP (12/99)]
An application for employers who want to offer health insurance to their employees.
Application for Waiver or Reduction of MassHealth Premium [HW (Rev. 10/09)]
An application for members who are having trouble paying their MassHealth, Children’s Medical Security Plan, or CommonHealth premiums.
- Application for Waiver or Reduction of MassHealth Premium [English] (PDF) | TEXT
- Solicitud para la exención o reducción de la prima de MassHealth (PDF) | TEXT
Member Forms
Not insured? Need help paying for health insurance? [OP-3 (05/09)]
A brochure that briefly explains what MassHealth is, what it offers, who can get it, and how to apply. It also describes other available health-care programs.
- You may be able to get free or low-cost health care even if you work or have health insurance [English] (PDF) | TEXT
- Es possible que usted pueda obtener cuidados de salud gratuitos o a bajo costo aunque trabaje o tenga seguro medico (PDF) | TEXT
To get this brochure in Cambodian, Chinese, Laotian, Brazilian Portuguese, Russian, or Vietnamese, please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss).
Help Getting Proof of U.S. Citizenship for Persons Born in Massachusetts [MRVS (10/08)]
A form for applicants and members born in Massachusetts who want help getting proof of their U.S. citizenship.
- Help Getting Proof of U.S. Citizenship for Persons Born in Massachusetts [English] (PDF) | TEXT
- Asistencia para obtener prueba de ciudadanía/nacionalidad de los E.E.U.U. para personas nacidas en Massachusetts (PDF) | TEXT
HIV brochure [HIV-1 (05/09)]
A brochure that briefly explains how HIV+ persons who meet certain requirements may be eligible for MassHealth.
- If you are HIV+, you can get health-care coverage [English] (PDF) | TEXT
- Si es VIH+, usted puede obtener cobertura de seguro medico (PDF) | TEXT
MassHealth Eligibility Representative Designation Form [ERD (03/08)]
A form used to designate an eligibility representative who can help the applicant or member with the responsibilities of applying for or getting MassHealth.
MassHealth Permission to Share Information Form [PSI (03/04)]
A form used when an applicant or member wants MassHealth to share their personal health information with someone other than their eligibility representative.
Notice of Privacy Practices [NPP (12/05)]
A pamphlet that describes how medical information may be used and disclosed, and how an applicant or member can get access to this information.
MassHealth Adult Disability Supplement [MADS-A (04/04)]
A form for adults who are applying for MassHealth based on their disability.
- MassHealth Adult Disability Supplement [English] (PDF) | TEXT
- Suplemento de discapacidad para adultos de MassHealth instrucciones para completar el suplemento (PDF) | RTF
MassHealth Child Disability Supplement [MADS-C (04/04)]
A form for children who are applying for MassHealth based on their disability.
MassHealth Medical Records Release Form [MADS-MR (04/04)]
A form used with the MADS-A and MADS-C to get medical information from a health-care provider so MassHealth can make a disability determination.
- MassHealth Medical Records Release Form [English] (PDF) | RTF
- Formulario de autorización para divulgar información médica de MassHealth (PDF) | RTF
MassHealth Asset Assessment for Potential MassHealth Eligibility [MH/AA (07/04)]
A form used to determine the amount of a person's assets when that person wants to find out if he or she may be eligible for MassHealth long-term-care benefits.
- MassHealth Asset Assessment for potential MassHealth eligibility [English] (PDF) | TEXT
- MassHealth Valoración de bienes para determinar si puede afiliarse a MassHealth (PDF) | TEXT
Financial Information Request (Solicitud de información financiera) [FIR (07/09)]
A form that is used by applicants and members to get bank records for MassHealth at no cost.
- Revere
- Springfield
- Taunton
- Tewksbury
How to Ask for a Fair Hearing/Fair Hearing Request Form [FHR/MCO-PCCBH-SCO (02/06)]
A form used by members who want to ask for a fair hearing and are enrolled in a managed care plan, managed care organization, the Primary Care Clinician (PCC) Plan's Behavioral Health Program, or a Senior Care Organization.
- How to Ask for a Fair Hearing/Fair Hearing Request Form [English] (PDF) | RTF
- Cómo pedir una audiencia imparcial/Formulario de petición de audiencia imparcial (PDF) | RTF
Senior Care Options brochure [SCO-1 (06/04)]
A brochure that explains the option of enrolling in a coordinated health plan called Senior Care Options for MassHealth members aged 65 or older.
Well-Child Care Claim Form (WCC/CF) and 5% Max Claim (WCC/5%CF) (09/09)
- Well-Child Care Claim Form (Formulario de reclamación de cuidado de rutina del niño)
- 5% Max Claim Form (Formulario de reclamación del máximo de 5%)
This information is provided by MassHealth.