Additional Information about Your Access to Employer Sponsored Health Insurance Coverage [ESI-1 (11/16)]

Available Formats

Authorization for Electronic Funds Transfer Payments [EFT-M (12/11)]

A form used by members to set up direct deposit with the State Treasurer.

Available Formats

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

A form used by applicants and members who want to ask for a fair hearing.

Available Formats

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.

Available Formats

Financial Information Request Form [FIR-1 (03/15)]

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

Available Formats

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.

Available Formats

Job Update [JU-1 (01/16)]

This form is used to tell MassHealth about a new job or a change in your job.

Available Formats

Long-Term-Care Supplement [LTC-SUPP (03/15)]

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

Available Formats

MassHealth Adult Disability Supplement [MADS-A (04/15)]

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

Available Formats

MassHealth Asset Assessment for Potential MassHealth Eligibility [MH/AA (05/15)]

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.

Available Formats

MassHealth Authorized Representative Designation Form [ARD (03/15)]

A form used to designate an authorized representative who can help the applicant or member with the responsibilities of applying for or getting MassHealth.

Available Formats

MassHealth Child Disability Supplement [MADS-C (04/15)]

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

Available Formats

MassHealth Medical Records Release Form [MADS-MR (04/15)]

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.

Available Formats

MassHealth Permission to Share Information Form [PSI (02/13)]

A form used when an applicant or member wants MassHealth to share their personal health information with someone other than their eligibility representative.

Available Formats

Noncustodial Parent Form [NCP-1 (04/15)]

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

Available Formats

Personal-Care-Attendant Supplement [PCA-SUPP (03/15)]

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

Available Formats

U.S. Citizenship/National Status Requirements for MassHealth and ConnectorCare Plans and Premium Tax Credits
Identity Requirements for MassHealth, ConnectorCare Plans and Premium Tax Credits, and the Health Safety Net [C+I (03/15)]

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

Available Formats

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.

Available Formats

  • 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.