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HIPAA forms for MassHealth Members

Use the forms below to choose an authorized representative, read about our privacy practices, or give MassHealth permission to share your information.
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Table of Contents

Authorized Representative Designation Form

Authorized Representative Designation Form [English] (PDF 145.41 KB)
Authorized Representative Designation Form [English] (DOC 64 KB)
Authorized Representative Designation Form (Large Print) (PDF 58.48 KB)
Formulario de designacion de representante autorizado (ARD-SP) (PDF 150.03 KB)
Formulario de designacion de representante autorizado (ARD-SP) (DOCX 44.08 KB)

MassHealth - Notice of Privacy Practices

Notice of Privacy Practices [English] (PDF 195.88 KB)
Notice of Privacy Practices [English] (DOC 38.5 KB)
Notificación Sobre las Normas de Confidencialidad (PDF 196.9 KB)
Notificación Sobre las Normas de Confidencialidad (DOC 46.5 KB)

Permission to Share Information Form

MassHealth Permission to Share Information (PSI) Form [English] (PDF 77.84 KB)
MassHealth Permission to Share Information (PSI) Form [English] (DOCX 18.05 KB)
MassHealth Permission to Share Information (PSI) Form Large Print (PDF 53.21 KB)
MassHealth Formulario de autorización para compartir información (PSI) (PDF 62.24 KB)
MassHealth Formulario de autorización para compartir información (PSI) (DOCX 23.08 KB)
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