MassHealth

Commonwealth of Massachusetts
EOHHS
www.mass.gov/masshealth

Commonwealth Connector
Commonwealth Care

Help Getting Proof of U.S. Citizenship for Persons Born in Massachusetts

FOR OFFICE USE ONLY

Date received:

For applicants or members born in Massachusetts who want help getting proof of their U.S. citizenship, please fill out, sign, and date this form and send it back to the one of the following addresses. 
If you are applying for long-term-care health benefits in a long-term-care facility, send your filled-out form to the MassHealth Enrollment Center (MEC) that is closest to where you live. 

MassHealth Enrollment Center 45-47 Spruce Street Chelsea, MA 02150

MassHealth Enrollment Center 21 Spring Street Suite 4 Taunton, MA 02780

MassHealth Enrollment Center 333 Bridge Street Springfield, MA 01103

MassHealth Enrollment Center 367 East Street Tewksbury, MA 01876

Otherwise, if you are applying for or are already getting health benefits, send your filled out form to:
MassHealth Enrollment Center P.O. Box 1231 Taunton, MA 02780

For applicants or members born outside Massachusetts who want help getting proof of their U.S. citizenship, MassHealth may be able to help you.  Please call MassHealth Customer Service at 1-800-841-2900 (TTY:  1-800-497-4648 for people with partial or total hearing loss).
Fill out one section below for EACH applicant or member who is applying for or getting benefits, was born in Massachusetts, and wants help getting proof of his or her U.S. citizenship through the Massachusetts Registry of Vital Records and Statistics.
Note:  When filling out the sections below, be sure to print clearly and make sure each applicant’s or member’s name is entered exactly as it would appear on his or her birth certificate.

Applicant’s/Member’s current last name First MI Suffix (ex.,“Jr.”)
Applicant’s/Member’s last name at time of birth (if different) First MI Suffix (ex., “Jr.”)
Date of birth Gender at time of birth (if different)
Massachusetts hospital name Massachusetts city of birth
Mother’s/Coparent’s last name (at time of applicant’s/member’s birth) First MI 
Mother’s maiden name
Father’s/Coparent’s last name (at time of applicant’s/member’s birth) First MI Suffix (ex., “Jr.”)

Applicant’s/Member’s current last name First MI Suffix (ex.,“Jr.”)
Applicant’s/Member’s last name at time of birth (if different) First MI Suffix (ex., “Jr.”)
Date of birth Gender at time of birth (if different)
Massachusetts hospital name Massachusetts city of birth
Mother’s/Coparent’s last name (at time of applicant’s/member’s birth) First MI 
Mother’s maiden name
Father’s/Coparent’s last name (at time of applicant’s/member’s birth) First MI Suffix (ex., “Jr.”)

X
Signature of person filling out form  
Date
X
Printed name of person filling out form
Social security number
Street address, city/town, state, zip code

MRVS (Rev. 02/12)  over


Applicant’s/Member’s current last name 
First 
MI 
Suffix (ex.,“Jr.”)
Applicant’s/Member’s last name at time of birth (if different) 
First 
MI 
Suffix (ex., “Jr.”)
Date of birth 
Gender at time of birth (if different)
Massachusetts hospital name Massachusetts city of birth
Mother’s/Coparent’s last name (at time of applicant’s/member’s birth) 
First 
MI 
Mother’s maiden name
Father’s/Coparent’s last name (at time of applicant’s/member’s birth) 
First 
MI 
Suffix (ex., “Jr.”)

Applicant’s/Member’s current last name
First 
MI 
Suffix (ex.,“Jr.”)
Applicant’s/Member’s last name at time of birth (if different) 
First 
MI 
Suffix (ex., “Jr.”)
Date of birth 
Gender at time of birth (if different)
Massachusetts hospital name Massachusetts city of birth
Mother’s/Coparent’s last name (at time of applicant’s/member’s birth) 
First 
MI 
Mother’s maiden name
Father’s/Coparent’s last name (at time of applicant’s/member’s birth) 
First 
MI 
Suffix (ex., “Jr.”)

Applicant’s/Member’s current last name 
First 
MI 
Suffix (ex.,“Jr.”)
Applicant’s/Member’s last name at time of birth (if different) 
First 
MI 
Suffix (ex., “Jr.”)
Date of birth Gender at time of birth (if different)
Massachusetts hospital name Massachusetts city of birth
Mother’s/Coparent’s last name (at time of applicant’s/member’s birth) 
First 
MI 
Mother’s maiden name
Father’s/Coparent’s last name (at time of applicant’s/member’s birth) 
First 
MI 
Suffix (ex., “Jr.”)


X
Signature of person filling out form  
Date
X
Printed name of person filling out form
Social security number
Street address, city/town, state, zip code