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MassHealth Member Forms

Various forms used by MassHealth members.

Additional Information about Your Access to Employer Sponsored Health Insurance Coverage [ESI-1 (11/16)]

Additional Resources for Additional Information about Your Access to Employer Sponsored Health Insurance Coverage [ESI-1 (11/16)]

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

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

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

Fair Hearing Request Form [FHR-1 (09/10)]

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

Additional Resources for Fair Hearing Request Form [FHR-1 (09/10)]

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.

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

Financial Information Request Form [FIR-1 (03/15)]

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

Additional Resources for Financial Information Request Form [FIR-1 (03/15)]

Help Getting Proof of U.S. Citizenship for Persons Born in Massachusetts [MRVS (02/12)]

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

Additional Resources for Help Getting Proof of U.S. Citizenship for Persons Born in Massachusetts [MRVS (02/12)]

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

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

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

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

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

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

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.

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

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.

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

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.

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

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.

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

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.

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

MassHealth Permission to Share Information Form [PSI (02/13)]

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

Additional Resources for MassHealth Permission to Share Information Form [PSI (02/13)]

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.

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

Personal-Care-Attendant Supplement [PCA-SUPP (03/15)]

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

Additional Resources for Personal-Care-Attendant Supplement [PCA-SUPP (03/15)]

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.

Additional Resources for 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)]

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.

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

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