We have tried to make the Medical Benefit Request easy for you to fill out. Be sure to read the instructions on the cover page before you begin. You must fill out the first five pages and sign the form. If any of the attached Medical Benefit Request supplements apply to you or any of your family members, you must also complete and return them with your Medical Benefit Request.
Your family includes you, your spouse, and your children under age 19, if you are all living together. If neither parent is living in the home, your family group may include children under age 19 and an adult caretaker relative who are all living together. If more than one family lives in your home and wants to apply for MassHealth, they will need to fill out a separate form.
You must give us proof of your monthly income before taxes and deductions for every person in your family. Proof may be two recent pay stubs, a U.S. tax return (if you are self-employed or have rental income), or copies of other check stubs you get, such as from unemployment, or pension check that shows the gross amount (before deductions). If you are self-employed or have rental income, we count your income after allowable deductions.
Mail the Medical Benefit Request and proof of your income to:
MassHealth Enrollment Center
Central Processing Unit
P.O. Box 290794
Charlestown, MA 02129-0214.
Your application package includes a voter registration form. MassHealth Enrollment Center staff can help you fill out this form. Your decision about signing up to vote has no affect on your getting MassHealth.
The Massachusetts Secretary of State's Elections Division has more information on how to register to vote.
You can also get the following from this site:
This information is provided by MassHealth.