• This page, COVID-19 Emergency Related Waivers​ for Members and Applicants, is offered by
  • MassHealth

COVID-19 Emergency Related Waivers​ for Members and Applicants

Use the forms on this page to assist with your MassHealth eligibility during the COVID-19 Emergency

Table of Contents

Self-Attestation Form

Use this form if you cannot send in paperwork to provide proof of eligibility factors (except citizenship and immigration) in the time frame requested on your Request for Information letter due to the COVID-19 emergency. 
English PDF | Word Spanish PDF | Word

Temporary Waiver of MassHealth Income Deductible

Use this form if you have an income deductible for your MassHealth benefits and meeting this deductible would cause undue financial hardship to you. By filling out this form, you are requesting a temporary waiver of the income deductible during the COVID-19 emergency. 
English PDF Spanish PDF

Premium Billing Hardship Waiver

Use this form if you pay premium bills for MassHealth or you have lost your MassHealth coverage because you did not pay your premium bill, and paying the MassHealth bills would present an undue financial hardship. During the COVID-19 national emergency, members may self-attest to a premium billing hardship waiver. 
English/Spanish PDF | Word

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