Well-Child Care Claim Form Family Assistance C.A.R.E. Coordinator: (Tel.) 1-800-
462-1120 

Parent/Guardian Name: Parent/Guardian SSN: 
Health Insurance Company: 

Remember: You do not need to pay this bill. MassHealth can pay your doctor 
directly. 

Fill out one section below for each copay, deductible, or coinsurance amount. 
Attach a copy of the bill, or if you paid the amount, a 
copy of the receipt showing how much you paid. 

Name of Child Child’s SSN Date of Visit 
Type of Visit (check . one) 
 
Physical Exam
Immunization  
Lab Test
Hearing Test 
Vision Test 
Did you pay this bill? 

Yes
No 
Amount 

Name of Child Child’s SSN Date of Visit 
Type of Visit (check  one) 

Physical Exam 
Immunization  
Lab Test 
Hearing Test  
Vision Test 
Did you pay this bill? 

Yes
No 
Amount 

Name of Child Child’s SSN Date of Visit 
Type of Visit (check  one) 

Physical Exam 
Immunization  
Lab Test 
Hearing Test  
Vision Test 
Did you pay this bill? 

Yes  
No 
Amount 

Name of Child Child’s SSN Date of Visit 
Type of Visit (check one) 

Physical Exam 
Immunization 
Lab Test 
Hearing Test 
Vision Test 
Did you pay this bill? 

Yes  
No 
Amount 

Name of Child Child’s SSN Date of Visit 
Type of Visit (check  one) 

Physical Exam 
Immunization  
Lab Test 
Hearing Test  
Vision Test 
Did you pay this bill? 
 
Yes 
No 
Amount 

Name of Child Child’s SSN Date of Visit 
Type of Visit (check one) 

Physical Exam
Immunization 
Lab Test 
Hearing Test 
Vision Test 
Did you pay this bill? 

Yes 
No 
Amount 

Name of Child Child’s SSN Date of Visit 
Type of Visit (check one) 
 
Physical Exam 
Immunization 
Lab Test  
Hearing Test  
Vision Test 
Did you pay this bill? 

Yes 
No 
Amount 

Name of Child Child’s SSN Date of Visit 
Type of Visit (check  one) 
 
Physical Exam 
Immunization  
Lab Test 
Hearing Test  
Vision Test 
Did you pay this bill? 

Yes 
No 
Amount 

When you have completed this form, send the claim form and a copy of the bill or 
receipt for each claim line in the envelope in your 
kit. If you do not have an envelope from your kit, send the claim to: 

MassHealth, BC & R, Family Assistance C.A.R.E. Coordinator, P.O. Box 120068, 
Boston, MA 02112. 

Commonwealth of Massachusetts  
Executive Office of Health and Human Services . Office of Medicaid 

WCC/CF (Rev. 09/09)