MassHealth
Executive Office of Health and Human Services 
600 Washington Street, 7th Floor 
Boston, MA 02111 

PNA Reporting Form 
for Deceased MassHealth Members 

Date


Member Information

Name: 
SSN: 
Date of birth: 
Date of death: 
Address before admission to the facility: 


Next of Kin or Responsible Party Information 

Name:
Address:
Relation to member:
Telephone number:  (    )


Facility Information

Name of facility:
Provider ID/Service location (PID/SL):
Address of facility:
Contact person:
Telephone number:  (    )


Burial Information

Name of funeral home:
Address of funeral home:
Contact person:
Telephone number:  (    )

Form completed by
Name:          
Date:


Check number:
Check amount: $


Mail check and completed form to:
EOHHS
MassHealth Accounting Unit
600 Washington Street, 7th Floor
Boston, MA  02111




LTC-014 (Rev. 09/12)