Commonwealth of Massachusetts • EOHHS 
www.mass.gov/masshealth

Notification of Birth 

Instructions: 

• Fill out this form online and print it out. 
• Sign and fax this form to 617-887-8777. 
• Mail the signed original to MassHealth, ATTN: NOB Unit, 
100 Hancock Street, 6th Floor, Quincy, MA 02171. 

Hospital Name 

Hospital Address 

Contact Name & Telephone No. 

Section I: Mother’s Information 

Mother’s MassHealth Member ID: 
Mother’s Name: 
Mother’s Address: 
Mother’s Date of Birth: 
Mother’s Tel. No: 
Mother’s Plan (Check the box to indicate mother’s plan and/or MCO.) 
PCC Plan Commonwealth Care MCO 
MassHealth MCO: 
Boston Medical Center HealthNet Plan 
Fallon Community Health Plan 
Health New England 
Neighborhood Health Plan 
Network Health Plan 
CeltiCare (Commonwealth Care MCO only) 

Section II: Child’s Information (Please Note: You must include all the 
information requested in this section, including the child’s birth weight and 
race.) Please list additional children on a separate sheet. 

Child’s Name (Last, First, M.I.) 
Child’s Date of Birth 
(MM/DD/YYYY) 
Gender 
Child’s Birth Weight 
lb/oz or grams 
Gestational age 
Child 1: 
M F 
Child 2: 
M F 
Race Code: 
1-American Indian 
2-Asian 
3-Black, not of Hispanic origin 
4-Hispanic 
5-White, not of Hispanic origin 
7-Interracial 
9-Race unknown or unreported 
Has an application for the child’s social security number been made 
through the hospital? 
Yes 
No 

I certify that the above-named child was born to the mother listed above. 

Signature and Title: 

Date: 


Section III: Child’s Information (for MassHealth use only) 

Child’s Member ID 
Start Date
Cat. 
Child’s Member ID 
Start Date
Cat. 

Child 1: 
Child 2: 

Note: MassHealth will return the original to the originating hospital. 

NOB-1 (Rev. 09/12) 





Purpose of MassHealth Notification of Birth (NOB-1) Form 

The NOB-1 form is used to: 

• process newborn MassHealth eligibility; 
• provide hospitals with a mechanism for receiving a newborn member ID in order 
to submit claims; 
• enroll newborns into MCOs; and 
• track federally required birth weight and race information. 

The MassHealth NOB-1 form is used by hospitals to facilitate eligibility 
determination and health-plan enrollment of newborns born to MassHealth-or 
Commonwealth Care-eligible women. Any child born to a woman who is eligible 
for MassHealth Standard or Limited is automatically eligible for MassHealth 
Standard for one year from the date of birth. A newborn of a woman who is 
enrolled in a MassHealth managed care organization (MCO) will be retroactively 
enrolled in the mother’s MCO to the baby’s date of birth. 
A newborn of a woman who is enrolled in the Primary Care Clinician (PCC) Plan 
or receiving services on a fee-for-service basis is provided MassHealth benefits 
on a fee-for-service basis until a health-plan selection is made or assigned, if 
the mother or guardian does not voluntarily select a health plan. A newborn of a 
woman enrolled in a Commonwealth Care MCO will be determined eligible for 
MassHealth Standard or Family Assistance. A MassHealth-eligible newborn will be 
retroactively enrolled in the same MCO as the mother, as long as the MCO is 
available to MassHealth members in the region where the mother lives. If the MCO 
is not available to the members in their region, no retroactive enrollment will 
occur and the newborn will receive MassHealth benefits on a fee-for-service 
basis until a health-plan selection has been made or assigned, if the mother or 
guardian does not voluntarily select a health plan for the newborn. 


Instructions for Completing the NOB-1 Form 

Section I: Mother’s Information 

• Mother’s Member ID: Enter the 12-digit MassHealth member ID of the mother. 
• Mother’s Name, Address, Date of Birth, and Tel. No.: Enter the name, address, 
date of birth, and phone number of the child’s mother. 
• Mother’s Plan: Check the appropriate box to indicate the mother’s plan and/or 
MCO. If the mother is in an MCO, indicate which one. 

Section II: Child’s Information 

• Child’s Name: Enter the child’s last name, first name, and middle initial. 
Only when the child is unnamed, enter the mother’s last name, followed by “Baby 
Boy” or “Baby Girl.” In the case of same-sex multiple births as yet unnamed, 
add a letter suffix to the child’s name, for example,“Smith, Baby Boy A” 
and “Smith, Baby Boy B.” If there are more than two children, please list them 
on a separate sheet. 
• Child’s Date of Birth: Enter the child’s date of birth, using MM/DD/YYYY 
format. 
• Gender: Enter “F” for female or “M” for male. 
• Birth weight: Enter the child’s birth weight in pounds and ounces or in grams. 
• Gestational Age: Enter the child’s gestational age. 
• Race: Check the appropriate box to indicate the child’s race. 
• Social Security Application: Indicate if an application for the child’s social 
security number has been made through the hospital. 
• Certification: Sign and date the form. 
Please include your title. The director of medical records or patient accounts 
manager of the hospital must sign the NOB-1. 

Mailing the Completed NOB-1 Form 

• Mail the signed original to: MassHealth, ATTN: NOB Unit, 100 Hancock Street, 
6th Floor, Quincy, MA 02171. MassHealth will return the original to the 
originating hospital once the form has been processed.