The Details
What you need
- Medical and Mental Health Provider Information
For each medical or mental health provider who has treated you since your health issues began, have the following ready:
- First and last name
- Practice address where you see the provider
- Practice phone number
- Work History
Have your work history for the past five years, including the dates you worked at each job.
How to apply
This application can be completed and submitted online:
MassHealth Adult Disability Supplement:
Available using Adobe sign available in English and Spanish Only for now.
MassHealth Child Disability Supplement:
Available using Adobe sign available in English and Spanish Only for now.
Any version of Adobe Acrobat can be used to complete this application including the free version of Adobe Reader.
Once all required fields have been completed, Adobe will allow you to submit electronically. A valid email address is needed to complete the form and verify your submission. This will be forwarded to MassHealth but not included as part of your MassHealth case information.
Please note that this form must be completed in one sitting. If you are not able to do so, you can print the form, complete the application by hand, and mail or fax the form and any supporting documents to MassHealth.
To complete the Adult Disability Supplement or Child Disability Supplement on your own:
- Download and print the Adult Disability Supplement or Child Disability Supplement PDF to fill it out.
- Complete, sign, and date the supplement and any medical releases.
- Collect any relevant medical records
Send your completed Disability Supplement, relevant medical records, and signed Medical Release Forms to:
Disability Evaluation Services (DES)
PO Box 2796
Worcester, MA 01613-2796
To complete the Adult Disability Supplement or Child Disability Supplement on your own:
- Download and print the Adult Disability Supplement or Child Disability Supplement PDF to fill it out.
- Complete, sign, and date the supplement and any medical releases
Fax your complete Disability Supplement, relevant medical records, and signed Medical Release Forms to:
Disability Evaluation Services (DES)
More info
Each supplement includes five copies of the Authorization to Release Protected Health Information Form (MADS-MR). You must complete a separate MADS-MR form for every medical and mental health provider that you include in your supplement.
You can fill out these forms online using Adobe sign:
Authorization to Release Protected Health Information Form (MADS-MR):
Available using Adobe sign available in English and Spanish Only for now. The other language forms will be accessible shortly.
DES will ask the providers you listed for your medical and treatment records. If you have any of your medical records, please send a copy with your complete disability supplement. If more information or tests are needed, a member of DES will get in touch with you.
If you want someone to help you complete the form and receive information for you, or if someone has legal authority to act on your behalf, please attach the corresponding, completed legal paperwork to your printed disability supplement (for example, an Authorized Representative Designation Form, guardianship form, or power of attorney form).
Authorized Representative Designation Form:
Downloads
Contact
Phone
Self-service available 24 hrs/day in English and Spanish. Other services available Monday-Friday 8 a.m.–5 p.m. Interpreter services are available.