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

Attestation of Application Fee Payment 


Federal law generally requires some applicants for enrollment or reenrollment 
into a Medicaid program to pay an application fee. Provider types subject to the 
fee are: 

• ICF-MR State Schools 
• Acute In-Patient Hospitals 
• Chronic In-Patient Hospitals 
• Psychiatric In-Patient Hospitals 
• Semi-Acute In-Patient Hospitals
• Skilled Nursing Facilities

All other providers are exempt from the fee. Providers who are required to pay 
the fee but enrolled in Medicare or another state’s Medicaid or CHIP program, 
and have paid the application to the Medicare contractor or the other state’s 
program, are also exempt. To claim this exemption, please complete this form and 
send it with your application, either as an attachment to your electronic 
application submission on the Provider Online Service Center (POSC) or with your 
paper application. 

Please complete the following required information, check off the applicable 
Attestation Fee Payment box below, and then read and sign the attestation 
statement. Return this completed and signed form with your application. 

Legal name: Doing business as (DBA) name: 

DBA address: 

Application tracking number (ATN): 

(The ATN is issued when the application is entered on the POSC or when an 
application is requested via MassHealth Customer 
Service.) 

Tax ID no.: NPI: 

Contact name: Phone: e-Mail: 

Attestation Fee Payment
 
Applicant is enrolled in Medicare and has paid an application fee for this 
service location to the Medicare contractor. 

Date paid: 

Provide either the PECOS Payment Tracking ID or the pay.gov payment tracking ID: 
 
Applicant is enrolled in another state’s Medicaid or Childeren’s Health 
Insurance Program (CHIP) and has paid an application fee for this service 
location to another state’s Medicaid or CHIP program. 

Date paid: State to which the application fee was paid: 

Please attach confirmation of application fee payment. 

Provide a contact name, phone number and any reference or tracking information 
associated with the Medicaid program you paid the fee to: 

Provider’s Attestation, Signature, and Date 

I certify under the pains and penalties of perjury that the information on this 
form and any attached statement that I have provided has been reviewed and 
signed by me, and is true, accurate, and complete, to the best of my knowledge. 
I also certify that I am the provider or, in the case of a legal entity, duly 
authorized to act on behalf of the provider. I understand that I may be subject 
to civil penalties or criminal prosecution for any falsification, omission, or 
concealment of any material fact contained herein. 

Provider’s signature (Signature and date stamps, or the signature of anyone 
other than the provider or a person legally authorized to sign on behalf of a 
legal entity, are not acceptable.) 

Printed legal name of provider: Date: 

This form is also available online at www.mass.gov/masshealth (go to Information 
for MassHealth Providers/MassHealth Provider Enrollment and 
credentialing/Enrollment, then go to the Application Fee section). 

PE-AAFP (04/13)