Third Party Liability Indicator 
Date: 
Head of Household: MassHealth ID No: Telephone No.: ( )

(Last, First, MI) 
(If you need more space to finish any section on this form, please use the back of this form.) 

1. Medicare Information 
Name: Claim No.: 
(Last, First, MI) 

Part A Start Date: Part A End Date: 
Part B Start Date: Part B End Date: 
Part C Carrier Name: Start Date: Part C End Date: 

2. Commercial Health Insurance Information 
.. New Policy .. Change Policy .. Terminate/Closed Policy .. Additional Policy .. Policy Ended Due to Leaving Job 
Policyholder’s Name: Date of Birth: MassHealth ID No. or SSN: Policy No.:

(Last, First, MI) 

Insurance Company Name: Group No.: Policy Start Date: Policy End Date: 

Insurance Address: Insurance Telephone No.: ( ) 
Employer/Union Name: Employer/Union Telephone No.: ( ) 
Family Members Covered: 

Name: MassHealth ID No: 
Name: MassHealth ID No: 
Name: MassHealth ID No: 
Name: MassHealth ID No: 


3. Access to Employer-Sponsored Health Insurance 
If not currently insured, does any family member’s employer offer health insurance? .. Yes .. No 
Employer/Union Name: Employer/Union Telephone No.: ( ) 
Employer/Union Address: 

Mail or fax this form to: 
MassHealth 
Third Party Liability Unit, P.O. Box 9212, Chelsea, MA 02150 
Tel.: 1-888-628-7526 • Fax: 617-357-7604 


TPLI-MH (Rev. 02/11)