Applications and Application-Related Publications

MassHealth Medical Benefit Request [MBR (03/12)]

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 Member Booklet [HCR-2 (03/12)]

A booklet for people who are under age 65 and who are not living in a nursing home or other long-term-care facility.

To get this booklet in Cambodian, Chinese, Haitian Creole, Laotian, Brazilian Portuguese, Russian, Vietnamese, or in Braille 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.

Senior Medical Benefit Request [SMBR (03/12)]

An application for seniors and people needing long-term-care services.

MassHealth and You Guide [MH + You Guide (03/12)]

A guide for seniors and for persons of any age needing long-term-care services.

To get this guide in Cambodian, Chinese, Haitian Creole, Laotian, Brazilian Portuguese, Russian, Vietnamese, or in Braille 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 (03/10)]

A form that provides complete information about acceptable proofs of U.S. citizenship/national status and identity.

Long-Term-Care Supplement [LTC-SUPP (03/12)]

A form for persons applying for or already receiving long-term-care services.

Personal-Care-Attendant Handbook

Personal-Care-Attendant Supplement [PCA-SUPP (08/08)]

A form for persons who need personal-care-attendant services.

MassHealth Buy-In [MHBI-1 (03/12)]

An application and brochure for people who are eligible for Medicare.

Fair Hearing Request Form [FHR-1 (09/10)]

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.

Member Forms

Absent-Parent Questions and Assignment of Rights [AP-1 (10/11)]

This form is for applicants or members whose children have a parent who is absent from the household, deceased, or unknown.
 

 

Not insured? Need help paying for health insurance? [OP-3 (03/12)]

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.

To get this brochure in Cambodian, Chinese, Haitian Creole, 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 (02/12)]

A form for applicants and members born in Massachusetts who want help getting proof of their U.S. citizenship.

HIV brochure [HIV-1 (03/12)]

A brochure that briefly explains how HIV+ persons who meet certain requirements may be eligible for MassHealth.

MassHealth Eligibility Representative Designation Form [ERD (01/12)]

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 (03/10)]

A form for adults who are applying for MassHealth based on their disability. This document includes five copies of the Medical Records Release Form.

MassHealth Child Disability Supplement [MADS-C (03/10)]

A form for children who are applying for MassHealth based on their disability. This document includes five copies of the Medical Records Release Form.

MassHealth Medical Records Release Form [MADS-MR (05/10)]

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 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.

Financial Information Request (Solicitud de información financiera) [FIR (01/12)]

A form that is used by applicants and members to get bank records for MassHealth at no cost.

How to Ask for a Fair Hearing/Fair Hearing Request Form [FHR/MCO-PCCBH-SCO (09/10)]

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.

PCC Plan Member Handbook [MAXI/PCC (12/10)]

This Member Handbook explains the PCC Plan and summarizes the MassHealth benefits for PCC Plan members.

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)

Forms used by Family Assistance members to keep track of their child's copays, deductibles, and coinsurance for reimbursement.

  • 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.