Voter Registration

If you are a US citizen, a resident of Massachusetts, and 18 years old on or before election day, you can register to vote. Just print out this voter registration form and bring or mail it to your town or city hall. If you need help, you can call 1-800-841-2900 (TTY: 1-800-497-4648 for the deaf, hard of hearing, and speech disabled).

Applications and Application-Related Publications

MassHealth Medical Benefit Request [MBR (01/13)]

An application for people who are under age 65 and who are not living in a nursing home or other long-term-care facility.

MassHealth Member Booklet [HCR-2 (01/13)]

A booklet for people who are under age 65 and who are not living in a nursing home or other long-term-care facility.

To get this booklet in Cambodian, Chinese, Haitian Creole, Laotian, Brazilian Portuguese, Russian, Vietnamese, or in Braille please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

MassHealth Enrollment Guide (11/07)

This guide explains how to choose a health plan and a primary care doctor, and how to enroll in a health plan.

Senior Medical Benefit Request [SMBR (01/13)]

An application for seniors and people needing long-term-care services.

MassHealth and You Guide [MH + You Guide (01/13)]

A guide for seniors and for persons of any age needing long-term-care services.

To get this guide in Cambodian, Chinese, Haitian Creole, Laotian, Brazilian Portuguese, Russian, Vietnamese, or in Braille please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

U.S. Citizenship/National Status and Identity Requirements for MassHealth [C+I (03/10)]

A form that provides complete information about acceptable proofs of U.S. citizenship/national status and identity.

Long-Term-Care Supplement [LTC-SUPP (01/13)]

A form for persons applying for or already receiving long-term-care services.

Personal-Care-Attendant Handbook

Personal-Care-Attendant Supplement [PCA-SUPP (10/12)]

A form for persons who need personal-care-attendant services.

MassHealth Buy-In [MHBI-1 (01/13)]

An application and brochure for people who are eligible for Medicare.

Fair Hearing Request Form [FHR-1 (09/10)]

A form used by applicants and members who want to ask for a fair hearing.

Insurance Partnership Employer Application [IP-ER-APP (12/99)]

An application for employers who want to offer health insurance to their employees.

Application for Waiver or Reduction of MassHealth Premium [HW (Rev. 10/09)]

An application for members who are having trouble paying their MassHealth, Children's Medical Security Plan, or CommonHealth premiums.

Member Forms

Absent-Parent Questions and Assignment of Rights [AP-1 (10/12)]

This form is for applicants or members whose children have a parent who is absent from the household, deceased, or unknown.
 

Not insured? Need help paying for health insurance? [OP-3 (01/13)]

A brochure that briefly explains what MassHealth is, what it offers, who can get it, and how to apply. It also describes other available health-care programs.

To get this brochure in Cambodian, Chinese, Haitian Creole, Laotian, Brazilian Portuguese, Russian, or Vietnamese please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss).

Help Getting Proof of U.S. Citizenship for Persons Born in Massachusetts [MRVS (02/12)]

A form for applicants and members born in Massachusetts who want help getting proof of their U.S. citizenship.

HIV brochure [HIV-1 (03/12)]

A brochure that briefly explains how HIV+ persons who meet certain requirements may be eligible for MassHealth.

MassHealth Eligibility Representative Designation Form [ERD (01/13)]

A form used to designate an eligibility representative who can help the applicant or member with the responsibilities of applying for or getting MassHealth.

MassHealth Permission to Share Information Form [PSI (02/13)]

A form used when an applicant or member wants MassHealth to share their personal health information with someone other than their eligibility representative.

Notice of Privacy Practices [NPP (12/05)]

A pamphlet that describes how medical information may be used and disclosed, and how an applicant or member can get access to this information.

MassHealth Adult Disability Supplement [MADS-A (03/10)]

A form for adults who are applying for MassHealth based on their disability. This document includes five copies of the Medical Records Release Form.

MassHealth Child Disability Supplement [MADS-C (03/10)]

A form for children who are applying for MassHealth based on their disability. This document includes five copies of the Medical Records Release Form.

MassHealth Medical Records Release Form [MADS-MR (05/10)]

A form used with the MADS-A and MADS-C to get medical information from a health-care provider so MassHealth can make a disability determination.

MassHealth Asset Assessment for Potential MassHealth Eligibility [MH/AA (07/04)]

A form used to determine the amount of a person's assets when that person wants to find out if he or she may be eligible for MassHealth long-term-care benefits.

Financial Information Request (Solicitud de información financiera) [FIR (01/12)]

A form that is used by applicants and members to get bank records for MassHealth at no cost.

Authorization for Electronic Funds Transfer Payments [EFT-M (12/11)]

A form used by members to set up direct deposit with the State Treasurer.

How to Ask for a Fair Hearing/Fair Hearing Request Form [FHR/MCO-PCCBH-SCO (09/10)]

A form used by members who want to ask for a fair hearing and are enrolled in a managed care plan, managed care organization, the Primary Care Clinician (PCC) Plan's Behavioral Health Program, or a Senior Care Organization.

PCC Plan Member Handbook [MAXI/PCC (12/10)]

This Member Handbook explains the PCC Plan and summarizes the MassHealth benefits for PCC Plan members.

Senior Care Options brochure [SCO-1 (06/04)]

A brochure that explains the option of enrolling in a coordinated health plan called Senior Care Options for MassHealth members aged 65 or older.

Well-Child Care Claim Form (WCC/CF) and 5% Max Claim (WCC/5%CF) (09/09)

Forms used by Family Assistance members to keep track of their child's copays, deductibles, and coinsurance for reimbursement.

  • Well-Child Care Claim Form (Formulario de reclamación de cuidado de rutina del niño)
  • 5% Max Claim Form (Formulario de reclamación del máximo de 5%)

This information is provided by MassHealth.