MassHealth Member Forms

A form for adults who are applying for MassHealth based on their disability. This document includes five copies of the Medical Records Release Form.

1. Affidavit to Verify Incarceration Status [AFF-IS (11/19)]
2. Affidavit to Verify Massachusetts Residency [AFF-MR (10/19)]
3. Affidavit to Verify Zero Income [AFF-ZI (10/19)]

A form used to determine the amount of a person's assets when that person wants to find out if he or she may be eligible for MassHealth long-term-care benefits.

A form used by members to set up direct deposit with the State Treasurer.

A form used with the MADS-A and MADS-C to get medical information from a health-care provider so MassHealth can make a disability determination.

A form used to designate an authorized representative who can help the applicant or member with the responsibilities of applying for or getting MassHealth.

A form for children who are applying for MassHealth based on their disability. This document includes five copies of the Medical Records Release Form.

A form used by applicants and members who want to ask for a fair hearing.

A form that is used by applicants and members to get bank records for MassHealth at no cost.

A form for applicants and members born in Massachusetts who want help getting proof of their U.S. citizenship.

This form is used to tell MassHealth about a new job or a change in your job.

1. Long-Term-Care Application Checklist [LTC AC (09/18)]
2. MassHealth Long-Term-Care Eligibility Review
3. Long-Term-Care Supplement [LTC-SUPP (03/20)]

A form used when an applicant or member wants MassHealth to share their personal health information with someone other than their eligibility representative.

This form is for applicants or members whose children have a parent who is absent from the household, deceased, or unknown.

A form for persons who need personal-care-attendant services.

MassHealth may reimburse members for out-of-pocket mail order pharmacy expenses for MassHealth covered services. This reimbursement may be available when a MassHealth member is required by their health insurer to fill a mail order prescription(s) and has to pay an expense (including co-insurance, copayments, and deductibles) up front in compliance with their insurance policy.

To request reimbursement for out-of-pocket mail order pharmacy expenses, please complete the Pharmacy Mail Order Expense Reimbursement Form. Instructions explaining the documentation that you’ll need, and how to submit your request, are included on the form.

A form that provides complete information about acceptable proofs of U.S. citizenship/national status and identity.