MassHealth 
Permission to Share Information (PSI) Form

Use this form if you want MassHealth to share the information we have about you with another person or organization, such as
a family member, friend, or other relative;
someone who helps take care of you;
someone who helps you fill out MassHealth forms; or
a social worker, lawyer, or health-care advocacy group.

Do not use this form if you want
information about yourself; 
information about your children under age 18 (You can usually get this without filling out any forms.); or
your eligibility and payment information to be shared with your health-care provider. (Your health-care provider can get information about your MassHealth eligibility and payment for services provided to you without you filling out any forms.)

Important: If you decide that you do need to fill out this form, you must fill out all sections completely. Please print clearly.

SECTION 1 Name of MassHealth applicant or member

Permission is given for MassHealth and its
representatives to share information listed in Section 2 about

(name of applicant or member whose information is to be shared)
Street
City/State/Zip
Date of birth Telephone number
MassHealth ID number
Please Note: If you do not have a MassHealth ID
number, please use your social security number, if one
has been issued, unless you are applying for or getting
only MassHealth Limited, Children’s Medical Security
Plan (CMSP), or Healthy Start benefits.

SECTION 2 What information do you want shared?
Check the box or boxes that apply.

I am giving MassHealth permission to share
eligibility notices and information about eligibility
for, and access to, MassHealth benefits, with
the person or organization listed in Section 3.
Please note such notices may contain financial
information. Check this box only if you want the
person or organization in Section 3 to be able to
contact MassHealth to get eligibility information
and copies of your eligibility notices.
Please Note: Eligibility notices include
information about all members of a household. If
you check this box, a separate PSI form must be
submitted and signed by each member of your
household who is 18 years or older. If we do not get
forms signed by each member of your household
who is 18 years or older, we will not be able to
honor your request.

a summary of my MassHealth claims from
(month/year)
to
(month/year)

MassHealth’s file containing my applications and related information

other (please be specific):

By giving MassHealth this permission to share information, 
are you also giving MassHealth permission to share drug and 
alcohol treatment information?

Yes. Share drug and alcohol treatment information.

No. Do not share drug and alcohol treatment information.

SECTION 3 Whom do you want us to share information with?
List the name of ONLY ONE person or organization
in this section. You must fill out another PSI form
if you want to name more than one person or
organization.
MassHealth may share the information listed in
Section 2 with Name of person or organization
In care of (name of person in organization to whom
mail should be sent)
Street
City/State/Zip
Telephone number
 
SECTION 4 Why do you want us to share your information?
Tell us why you want to share the information listed
in Section 2. If you leave this section blank, we will
assume you mean “at my request.”

SECTION 5 End of permission
This PSI will end in 18 months unless you specify an
end date here.

SECTION 6 Your signature
I understand the following.

When the person or organization named in
Section 3 gets this information from MassHealth,
that person or organization may be able to share it
with others without my permission. If they do so,
federal and state privacy laws may not protect the
information.

I need to send this PSI to the appropriate address
on the back page of this brochure.

I may cancel this permission at any time by
sending a letter to Privacy Office,
600 Washington Street, Boston, MA 02111.

If I cancel this permission, MassHealth cannot
take back any information that it shared when it
had my permission to do so.

If I do not give MassHealth permission to share
information, or if I cancel my permission to share
information with the person or organization named
in Section 3, my MassHealth benefits will not be
affected in any way.

In certain circumstances, MassHealth may not
honor my request to share information.
Name of applicant or member
Signature of applicant or member
Date
(See other side.)

SECTION 7 Signature/Legal guardian
Fill out the following section if this form is being filled
out by someone who has the legal authority to act on
behalf of the applicant or member (such as the parent
of a minor child, an eligibility representative, or a
legal guardian).
Printed name of person filling out this form
Signature of person filling out this form
Date
Address
Telephone number
Authority of person filling out this form to act on
behalf of the applicant or member:*
* If this form is being filled out by someone who has been
appointed by a court as a legal guardian or conservator,
or who has power of attorney or health-care proxy, a
copy of the applicable legal document must be attached.

Where to send this form
Please follow the instructions below.
If you are applying for health benefits and wish
to submit a PSI, send it to
MassHealth Enrollment Center
Central Processing Unit
P.O. Box 290794
Charlestown, MA 02129-0214

If you are already getting health benefits and
wish to submit a PSI, send it to
MassHealth Enrollment Center
P.O. Box 1231
Taunton, MA 02780

If you are authorizing only specific information
to be shared (such as your claims information or
application file), and have checked off the second,
third, or fourth box in Section 2, send the PSI to
Privacy Office
600 Washington Street
Boston, MA 02111


PSI (Rev. 02/13)