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

MassHealth - Notice of Privacy Practices

Open PDF file, 195.88 KB,  Notice of Privacy Practices [English] (English, PDF 195.88 KB)
Open DOC file, 38.5 KB,  Notice of Privacy Practices [English] (English, DOC 38.5 KB)
Open PDF file, 196.9 KB,  Notificación Sobre las Normas de Confidencialidad (English, PDF 196.9 KB)
Open DOC file, 46.5 KB,  Notificación Sobre las Normas de Confidencialidad (English, DOC 46.5 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,  MassHealth Permission to Share Information (PSI) Form (Spanish) (Spanish, PDF 300.32 KB)
Open DOCX file, 26.8 KB,  MassHealth Permission to Share Information (PSI) Form (Spanish) (Spanish, DOCX 26.8 KB)

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