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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.

If you need one of the forms in a language other than Spanish (find the Spanish versions on the page below), you can request on here: MassHealth HIPAA  Forms for non-English and Spanish Speakers.

 

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Authorized Representative Designation Form

Authorized Representative Designation Form (English, PDF 186.23 KB)
Authorized Representative Designation Form (English, DOCX 32.13 KB)
Authorized Representative Designation Form (Large Print) (English, PDF 57.35 KB)
Authorized Representative Designation Form (Spanish) (Spanish, PDF 222.34 KB)
Authorized Representative Designation Form (Spanish) (Spanish, DOCX 32.47 KB)

MassHealth - Notice of Privacy Practices

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

Permission to Share Information Form

MassHealth Permission to Share Information (PSI) Form (English, PDF 319.15 KB)
MassHealth Permission to Share Information (PSI) Form (English, DOCX 26.46 KB)
MassHealth Permission to Share Information (PSI) Form Large Print (English, PDF 106.66 KB)
MassHealth Permission to Share Information (PSI) Form (Spanish) (Spanish, PDF 300.32 KB)
MassHealth Permission to Share Information (PSI) Form (Spanish) (Spanish, DOCX 26.8 KB)

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