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MassHealth Member Forms

Various forms used by MassHealth members.

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

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

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

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Fair Hearing Request Form [FHR-1 (04/19)]

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

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How to Ask for a Fair Hearing/Fair Hearing Request Form [FHR/MCO-PCCBH-SCO (09/10)]

A form used by members who want to ask for a fair hearing and are enrolled in a managed care plan, managed care organization, the Primary Care Clinician (PCC) Plan's Behavioral Health Program, or a Senior Care Organization.

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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.

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

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

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

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

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Long-Term-Care Supplement [LTC-SUPP (03/15)]

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

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

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

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MassHealth Adult Disability Supplement [MADS-A (04/15)]

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

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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.

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MassHealth Authorized Representative Designation Form [ARD (01/18)]

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

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MassHealth Child Disability Supplement [MADS-C (04/15)]

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

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MassHealth Medical Records Release Form [MADS-MR (04/15)]

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.

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MassHealth Permission to Share Information Form [PSI (11/18)]

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

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Noncustodial Parent Form [NCP-1 (04/15)]

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

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

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

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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)]

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

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Well-Child Care Claim Form (WCC/CF) and 5% Max Claim (WCC/5%CF) (09/09)

Forms used by Family Assistance members to keep track of their child's copays, deductibles, and coinsurance for reimbursement.

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