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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

Open PDF file, 58.59 KB,  Authorized Representative Designation Form Instructions (English, PDF 58.59 KB)
Open DOCX file, 17.28 KB,  Authorized Representative Designation Form Instructions (English, DOCX 17.28 KB)
Authorized Representative Designation Form 

MassHealth - Notice of Privacy Practices

Open PDF file, 204.61 KB,  MassHealth Notice of Privacy Practices (English, PDF 204.61 KB)
Open DOCX file, 21.72 KB,  MassHealth Notice of Privacy Practices (English, DOCX 21.72 KB)
Open PDF file, 48.49 KB,  MassHealth Notice of Privacy Practices (Large Print) (English, PDF 48.49 KB)

Permission to Share Information Form

Open PDF file, 319.15 KB,  MassHealth Permission to Share Information (PSI) Form (English, PDF 319.15 KB)
Open DOCX file, 26.46 KB,  MassHealth Permission to Share Information (PSI) Form (English, DOCX 26.46 KB)
Open PDF file, 106.66 KB,  MassHealth Permission to Share Information (PSI) Form Large Print (English, PDF 106.66 KB)
Open PDF file, 300.32 KB,  Formulario de autorización para divulgar información (PSI) (Spanish, PDF 300.32 KB)
Open DOCX file, 26.8 KB,  Formulario de autorización para divulgar información (PSI) (Spanish, DOCX 26.8 KB)

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