This page, HIPAA forms for MassHealth Members, is offered by
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HIPAA forms for MassHealth Members

Use these forms to choose an authorized representative, read about privacy, give permission to share your information, or get a copy of your records.

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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HIPAA forms for MassHealth Members

Table of Contents

Authorized Representative Designation Form

Authorization to Release MassHealth or Health Connector Records

MassHealth - Notice of Privacy Practices

Permission to Share Information Form

Help Us Improve Mass.gov with your feedback