Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111
www.mass.gov/dma	
			MassHealth
			PACE Bulletin 1
			October 2002

	TO:	PACE (Program for All-Inclusive Care of the Elderly) Providers Participating in MassHealth
	FROM:	Wendy E. Warring, Commissioner

	RE:	Request for Services Form

Revision to Request for	The Request for Services form (formerly called the MassHealth Long 
Services Form 	Term Care Assessment form for PACE providers) has been revised in an 
	effort to facilitate communication between providers and the Division.  
	Effective October 1, 2002, the Division or its agent will accept only the 
	revised Request for Services form.  To determine the applicant’s or 
	member’s clinical eligibility, PACE providers must complete this form and 
	submit it with the Minimum Data Set (MDS-HC) to their local Aging 
	Services Access Points (ASAPs), the Division’s agent.

Completing the Form  	A nurse, licensed by the Massachusetts Board of Registration in Nursing 
	as a registered nurse, must complete the Request for Services form.

Obtaining the  Form	A copy of the Request for Services form is attached.  You may photocopy
	the form as needed.  To obtain supplies of the form, mail or fax a written 
	request to the following address or fax number.
	
		MassHealth
		Forms Distribution
		P.O. Box 9101
		Somerville, MA  02145
		Fax:  617-576-4087	

Effective Date 	You must begin using this form by October 1, 2002.  Please discard all
	previous versions of this form. 

Questions	If you have any questions about this bulletin, please contact MassHealth Provider Services at 617-628‑4141 or 1‑800‑325-5231.