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MassHealth Member Forms

Various forms used by MassHealth members.

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Table of Contents

Access to Employer-Sponsored Health Insurance Coverage [ESI-1 (11/18)]

Authorization for Electronic Funds Transfer Payments [EFT-M (12/11)]

Fair Hearing Request Form [FHR-1 (02/24)]

Financial Information Request Form [FIR-1 (06/16)]

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

Help Getting Proof of U.S. Citizenship for Persons Born in Massachusetts [MRVS (01/19)]

Job Update [JU-1 (01/16)]

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

Long-Term-Care Application Checklist [LTC AC (09/18)]

Helpful tips for applying for MassHealth Long-Term-Care (LTC) benefits.

MassHealth Long-Term-Care Eligibility Review

Long-Term-Care Supplement [LTC-SUPP (03/20)]

A form for persons applying for or already receiving long-term-care services.


MassHealth Adult Disability Supplement [MADS-A (07/21)]

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

MassHealth Asset Assessment for Potential MassHealth Eligibility [MH/AA (05/15)]

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.

MassHealth Authorized Representative Designation Form [ARD (11/22)]

MassHealth Child Disability Supplement [MADS-C (07/21)]

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

Authorization to Release Protected Health Information [MADS-MR (07/21)]

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.

MassHealth Permission to Share Information Form [PSI (02/23)]

Noncustodial Parent Form [NCP-1 (06/22)]

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

Personal-Care-Attendant Supplement [PCA-SUPP (11/18)]

Reimbursement for Mail Order Pharmacy Expenses

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.

U.S. Citizenship/National Status Requirements for MassHealth and ConnectorCare Plans and Premium Tax Credits Identity Requirements for MassHealth, ConnectorCare Plans and Premium Tax Credits, and the Health Safety Net [C+I (03/15)]

Affidavit to Verify Incarceration Status [AFF-IS (11/19)]

Affidavit to Verify Massachusetts Residency [AFF-MR (10/19)]

Affidavit to Verify Zero Income [AFF-ZI (10/19)]

Attestation Form to Verify Income [AFVI (08/22)]

Verification of Self-Employment Income [INVF (09/22)]



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