LEA Provider Revalidation Information and Resources

LEA Provider Revalidation Information Resources.

All MassHealth participating providers, including LEAS, must disclose information regarding ownership and control, business transactions, and criminal convictions, including submission of all relevant tax identification numbers (TINs), in order to ensure proper administration of the MassHealth program.  This is referred to as provider validation. Below are resources that will assist LEAs as they complete the required documentation for provider validation.  

MassHealth Revalidation Letter

Each participating LEA receives this letter, which outlines the required documentation for LEA provider validation.

• MassHealth Revalidation Letter 2023-sample

Completing the Provider Enrollment-Federally Required Disclosure (PE-FRD) Form

This document provides supplemental instructions specific to LEAs that they should consult when completing the Provider Enrollment Federally Required Disclosures (PE-FRD) FRDF.

•  Completing the Federally Required Disclosure Form

Sample Completed Provider Enrollment (PE-FRD) Form

To assist LEAs with completing the PE-FRD, MassHealth created three sample completed FRDFs:

• Charter School sample (PE-FRD)
• Public School sample (PE-FRD)
• Regional School sample (PE-FRD)

You will find links to forms that may be required, depending on circumstances in Additional Resources here:

Additional Resources

Federally Required Disclosures Form for Entities [PE-FRD-E]

Federally Required Disclosures Form for Entities [PE-FRD-E]

Massachusetts Substitute W-9 Form

Massachusetts Substitute W-9 Form

MassHealth Provider Change of Address Form

MassHealth Provider Change of Address Form

MassHealth Trading Partner Agreement

MassHealth Trading Partner Agreement