Self-Attestation Form
Temporary Waiver of MassHealth Income Deductible
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.
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