Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth Criminal Offender Record Information (CORI) Request Form MassHealth Customer Service has been certified by the Criminal History Systems Board for access to conviction and pending criminal case data. As a participating or applying MassHealth provider, I understand that a criminal record check will be conducted for conviction and pending criminal case information only and that it will not necessarily disqualify me. I hereby certify under the pains and penalties of perjury that the information on this form and any attachments that I have provided, has been reviewed and is true, accurate, and complete, to the best of my knowledge. 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. (Signature and date stamps, or the signature of anyone other than the provider or applicant, are not acceptable.) Signature of provider or applicant Last name, first name, middle name (Please print.) Maiden name or alias (if applicable) Place of birth Date of birth Social security number (Required) Mother’s maiden name Current address Former address Gender: M F Height Weight Eye color State driver’s license number Note: Please attach a copy of your driver's licence so that MassHealth can validate the information you provided above. CRF-1 (Rev. 10/12)