Getting Started

You can ll out the Medical Benet Request (MBR) on your computer, then print it. Or, you can print a blank copy and ll it out by hand. Make sure you sign and date the MBR on page 7. Then send it with proof of your income and proof of your U.S. citizenship/national status and identity to the address listed on the MBR instruction page. To ll out the MBR on-line, use the mouse to click on the rst eld you want to ll out on each page. Type the necessary information, then press the Tab key to move to the next eld, or use the mouse to click on the next eld. To ll a check box, click on the box using the mouse, or tab to the eld, and when the box has a dotted line around it, press the enter key. If you need to go back to another eld, click on that eld with your mouse. To go from one page to the next, tab to Please go to the next page., and when highlighted, press tab, or use the mouse to click on the rst eld on each page. After you print the lled-out MBR, YOU MUST click on the Clear entire form button at the bottom of page 7. This will remove all the information you entered on the MBR so no one can see your personal information.

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Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth

Medical Benet Request

Instructions

NOTE: Information entered into this form cannot be saved, so be sure to print a copy of the filled-out form before closing it.

Please read these instructions before you ll out the application.

Dear Applicant: This is your application for MassHealth, the Childrens Medical Security Plan (CMSP), Healthy Start, and the Health Safety Net*. MassHealth gives health-care coverage and helps pay for health-insurance premiums for families, children, and individuals. The kind of coverage you get depends on your family size, income, and other circumstances. After your application is lled out and reviewed, MassHealth will give you the most complete coverage that you qualify for. This application is also used to apply for Commonwealth Care. Commonwealth Care is a program administered by the Commonwealth Health Insurance Connector Authority (the Health Connector) for certain adults who are not eligible for MassHealth. Commonwealth Care helps pay for health-insurance premiums for health plans that are approved by the Health Connector. For more information, see pages 3 and 21 in the MassHealth Member Booklet. This application is for people who live in Massachusetts, are not living in or about to go into a nursing home, and are under age 65. This application may also be used by people of any age who are parents of children under age 19, or who are adult relatives living with and taking care of children under age 19 when neither parent is living in the home, or who are disabled and work 40 or more hours a month or are currently working and have worked at least 240 hours in the six months immediately before the month of the MassHealth application. If this application is not for you, call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled). Please list only one family group on an application. A family group can be parents, stepparents, or adoptive parents of any age and any of their children under age 19 who are all living together. If no parents are living at home, a family group may be siblings under age 19, or children under age 19 and an adult related by blood, adoption, or marriage, or a spouse or former spouse of one of those relatives who are all living together. A family group can also be an individual or a married couple who are living together with no children under the age of 19. If more than one family group lives in your home, each family group must ll out a separate application. MassHealth will send all eligibility notices to the person who is your head of household, and to your eligibility representative, if you have one. Please read the attached MassHealth Member Booklet carefully before you ll out the application. Keep the booklet. It may answer questions you have later. When you ll out the application, be sure to: Answer all questions, and ll out all sections and any supplements that apply to you and your family. Sign and date the application. The head of household, all applicants aged 18 or older, and all parents of any age who have children living with them must sign. Send proof of all income, like a copy of one recent pay stub. (You do not have to send proof of social security or SSI income.) Send proof of your HIV-positive status only if you want to see if you are eligible for MassHealth because you are HIV positive. Send proof of U.S. citizenship/national status and proof of identity, like U.S. passports or U.S. naturalization papers. You can also prove U.S. citizenship with a U.S. birth certicate or a U.S. hospital birth record. You can also prove identity with a drivers license, some other form of government-issued identity card, or a school identication card. We may be able to prove your identity through the Massachusetts Registry of Motor Vehicles records if you have a Massachusetts drivers license or a Massachusetts ID card. Once you give MassHealth proof of your U.S. citizenship/national status and identity, you will not have to give us this proof again. You must give us proof of identity for all family members who are applying. Seniors and disabled persons who get or can get Medicare or Supplemental Security Income (SSI), or disabled persons who get Social Security Disability (SSDI) do not have to give proof of their U.S. citizenship/ national status and identity. A child born to a mother who was getting MassHealth on the date of the childs birth does not have to give proof of U.S. citizenship/national status and identity. (See pages 28-29 in the MassHealth Member Booklet for complete information about acceptable proofs.) Send a copy of both sides of all immigration cards (or other documents that show immigration status) for every family member who is not a U.S. citizen/national and who is applying for MassHealth or Commonwealth Care, except for MassHealth Limited, CMSP, Healthy Start, or the Health Safety Net. (See Supplement C.) Please give us a social security number (SSN) or proof that you have applied for an SSN for every applicant. Applicants for MassHealth Limited do not need to provide a social security number or proof of an application for a social security number. * Information you provide on this application will be used to determine low-income patient status for provider payments from the Health Safety Net.

MBR-1 (Rev. 03/13)

over

Sign and date the application after you ll it out. Send the application and all other needed papers to: MassHealth Enrollment Center Central Processing Unit P.O. Box 290794 Charlestown, MA 02129-0214 The information you give us is kept condential, as required by state and federal laws. If you want us to share information about your MassHealth eligibility (including copies of notices we send you) with someone other than your eligibility representative, if you have one, please call MassHealth to get a MassHealth Permission to Share Information Form.

When lling out this application, please remember the following.

Make sure you ll out the application correctly and completely. If we need to contact you to get more information because we do not understand what you entered on the application, it will take us longer to decide if you are eligible or not for health benets. Make sure on pages 2 through 4 of the application in the sections Working Income, Nonworking Income, and College Student that each family member who has income and/or is aged 19 or older lls out each of these sections correctly. Please remember when lling out the Health Insurance section on pages 4 and 5, that: Part A is for listing the health insurance you have now, and Part B is for health insurance you may be eligible for; and you will not be eligible for Commonwealth Care if you have or can get insurance from a government insurance program including, but not limited to: - Medicare; - TRICARE (dependents of the military); - Medical Security Program (through the Division of Unemployment Assistance); or - student health insurance from a Massachusetts school. Make sure on page 6 of the application in the section Injury, Illness, Disability, or Accommodation that you answer yes or no to all of the questions. Do not leave any answer blank. If you answer yes to either question on page 6 of the application in the section Absent Parent, then you must ll out Supplement B according to the instructions for Supplement B. If the other parent of the child is living in the same household as the child but does not want to apply for MassHealth, make sure to list that parent on page 1 of the application in the section Other Family Members. If you have any questions about this application or the information you need to send, please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled). When we get your lled-out, signed, and dated application, we will review it. If more information is needed, we will write or call you. Once we get all needed information, we will make a decision about your eligibility. We will send you a written notice about this decision. If you are determined eligible for MassHealth, show this notice right away to any health-care provider if you already paid for medical services that would be covered by MassHealth during your eligibility period. If the health-care provider determines that MassHealth will pay for these services, the provider will refund what you paid. To start lling out this application, please turn to page 1 of this application. Remember, you must read, sign, and date page 7 after you have lled out the application.

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Click here to fill out the form.

This form is valid only if it has not been changed in any way, other than by entering the information requested.

Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth

Medical Benet Request

For office use only

IMPORTANT: Please do not leave this information on yourreceived: computer screen where Date unauthorized persons may be able to read confidential personal information. To fill out this form on your computer screen, use the mouse to click in the first form field (last name), type your entry, then press the Tab key to go to the next field.

This is an application for MassHealth, the Childrens Medical Security Plan (CMSP), Healthy Start, Commonwealth Care, and the Health Safety Net. You do not have to be a U.S. citizen/national to get these benets. Please print clearly. Please answer all questions and ll out all sections and any supplements that apply to you and your family. If you need more space to nish any section on this form, please use a separate sheet of paper (include your name and social security number), and attach it to this form.
HOH

Head of Household
1. Last name First name MI Street address homeless City yes City State Zip

Mailing address (if different from street address or if living in a shelter) Is this person applying? Date of birth / yes

State no Social security number* Written language choice Work: ( )

Zip
Type all nine digits without hyphens or spaces.

no If yes, is this person a U.S. citizen/national? Gender M F Spoken language choice Cell: ( )

/ mm/dd/yy )

C I

Telephone numbers Home: ( Race (optional )

Area code and phone number (without parentheses, spaces, or hyphens).

Ethnicity (optional )

E-mail

Other Family Members

List all other members of your family group. Do not repeat head of household information in this section. See instruction page for description of a family group. 2. Last name Is this person applying? Date of birth Race (optional ) 3. Last name Is this person applying? Date of birth Race (optional ) 4. Last name Is this person applying? Date of birth Race (optional ) / yes / / yes / / yes / First name no If yes, is this person a U.S. citizen/national? Gender M F Spoken language choice yes MI no Social security number* Written language choice
C I

Ethnicity (optional )

Relationship to head of household First name MI yes no Social security number* Written language choice
C I

no If yes, is this person a U.S. citizen/national? Gender M F Spoken language choice

Ethnicity (optional )

Relationship to head of household First name MI yes no Social security number* Written language choice
C I

no If yes, is this person a U.S. citizen/national? Gender M F Spoken language choice

Ethnicity (optional )

Relationship to head of household

*Applicants must provide a social security number if one has been issued. Applicants for MassHealth Limited are not required to provide a social security number or proof of application for a social security number.

Pregnancy
Are you or any family member pregnant? Are you or this person pregnant with: yes 1 baby? no Name: twins? triplets? If more, how many? ___________ Due date / /

PRG

MBR-1 (Rev. 03/13)

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MAR

Residency (You must ll out this section.)

Are you and all members of your household who are applying for benets living in Massachusetts with the intention to stay? yes no If no, list the names of the members of your household (including yourself)* who are applying and who are not residents of Massachusetts and who intend to leave. *Do not include infants born in Massachusetts who have not left the state.

General instructions for lling out the Working Income, Nonworking Income, AND College Student sections
Each family member who has income and/or is aged 19 or older must ll out all sections on this page through page 4.
EIN

Working Income (You must ll out this section.)

1. Name Is this person currently working or seasonally employed? (You must answer this question.) yes no If yes, ll out the Employer Information section below. If no, answer the next two questions below. You do not have to ll out the Employer Information section below. Has this person worked in the last 12 months before the date of application? yes no If yes, how much did this person earn in the last 12 months before taxes and deductions? Note: If you answered yes to this question, you MUST enter a dollar amount on this line. $ If no, go to the next section (Nonworking Income).

Employer Information Employer name

Employer address, and telephone number Type of work (Check all that apply.) Number of hours per week full-time day labor part-time seasonal yearly wage: $ self-employed sheltered workshop yearly wage: $ Weekly pay before deductions $ Date began getting this amount of pay / /

yes no Is health insurance offered that would cover doctors visits and hospitalizations? (Answer yes even if you cannot get it now, chose not to sign up for it, or dropped insurance that was available.) If you answered no to the above question, was health insurance offered in the last six months? yes no Send proof of income, like a copy of one recent pay stub. If self-employed, see the MassHealth Member Booklet for information about the needed proof. 2. Name Is this person currently working or seasonally employed? (You must answer this question.) yes no If yes, ll out the Employer Information section below. If no, answer the next two questions below. You do not have to ll out the Employer Information section below. Has this person worked in the last 12 months before the date of application? yes no If yes, how much did this person earn in the last 12 months before taxes and deductions? Note: If you answered yes to this question, you MUST enter a dollar amount on this line. $ If no, go to the next section (Nonworking Income).

Employer Information Employer name

Employer address, and telephone number Type of work (Check all that apply.) Number of hours per week full-time day labor part-time seasonal yearly wage: $ self-employed sheltered workshop yearly wage: $ Weekly pay before deductions $ Date began getting this amount of pay / /

yes no Is health insurance offered that would cover doctors visits and hospitalizations? (Answer yes even if you cannot get it now, chose not to sign up for it, or dropped insurance that was available.) If you answered no to the above question, was health insurance offered in the last six months? yes no Send proof of income, like a copy of one recent pay stub. If self-employed, see the MassHealth Member Booklet for information about the needed proof.

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Nonworking Income (You must ll out this section.)

REN

Rental Income

Do you or any family member get rental income? (You must answer this question.)

yes

no

If yes, enter the monthly amount of rental income (before taxes and deductions) on this line. $ Name of person getting rental income If no, go to the next section (Unemployment Benefits). Send proof of rental income.
UIN

Unemployment Benefits Are you or any family member getting an unemployment check? (You must answer this question.)
If yes, ll out this section and answer all questions. Send proof of unemployment benets. If no, go to the next section (Other Nonworking Income). Name of person getting unemployment benets yes no Is this check from the Commonwealth of Massachusetts? If yes, in the 12 months before this person became unemployed, did this person work for an employer in Massachusetts? (Do not include federal employers, like the U.S. Postal Service.) Enter the monthly amount of unemployment benets (before taxes and deductions). $ Name of person getting unemployment benets yes no Is this check from the Commonwealth of Massachusetts? If yes, in the 12 months before this person became unemployed, did this person work for an employer in Massachusetts? (Do not include federal employers, like the U.S. Postal Service.) Enter the monthly amount of unemployment benets (before taxes and deductions). $ yes yes

yes

no

no

no

UIN

Other Nonworking Income

Do you or any family member have any other income? (You must answer this question.)

yes

no

If yes, ll out this section. If no, go to the next section (College Student). Please describe the source of the income (where it comes from) for each family member. If anyone has more than one source, list on separate lines. Send proof. Some types of other income are: (You do not have to send proof of social security or SSI income.) alimony dividends or interest social security veterans benets (federal, state, or city) annuities pensions SSI workers compensation child support retirement trusts other (Please describe below.) Name Source (where the income comes from) Name Source (where the income comes from) Name Source (where the income comes from) Type of income (all that apply from list above) Monthly amount before taxes $ Type of income (all that apply from list above) Monthly amount before taxes $ Type of income (all that apply from list above) Monthly amount before taxes $

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College Student (You must ll out this section.)

Are you or any family member a college student? (You must answer this question.) yes no If yes, ll out this section and answer all questions. If no, go to the next section (Health Insurance You Have Now and Subsidized Health Insurance You May Be Eligible For). 1. Name of college student

Is this person eligible for health insurance from college? yes no Is this person a college student in Massachusetts with at least 75% of a full-time schedule? yes no (Note: If you are not sure that this person has 75% of a full-time schedule, contact the school to nd out if the number of credits the student is taking would require the student to get the health insurance the school offers to students.) If yes, is this student planning to get health-insurance coverage from the school, but is waiting for coverage to start? yes no If yes, what is the date that the school health-insurance coverage starts? ____ / ____ / ____ 2. Name of college student yes no Is this person eligible for health insurance from college? Is this person a college student in Massachusetts with at least 75% of a full-time schedule? yes no (Note: If you are not sure that this person has 75% of a full-time schedule, contact the school to nd out if the number of credits the student is taking would require the student to get the health insurance the school offers to students.) If yes, is this student planning to get health-insurance coverage from the school, but is waiting for coverage to start? yes no If yes, what is the date that the school health-insurance coverage starts? ____ / ____ / ____

STU

Health Insurance You Have Now and Subsidized Health Insurance You May Be Eligible For

Even if you or any family member have other health insurance, MassHealth may be able to help you pay your premiums. Health insurance can be from an employer, an absent parent, a union, a school, Medicare, or Medicare supplemental insurance, like Medex. All applicants must ll out the health insurance section. Do not include MassHealth or any health plan you enrolled in through Commonwealth Care when answering the questions below. Do you or any family member get Medicare benets? yes no If yes, name(s): Claim number(s): Do you or any family member have health insurance other than Medicare? yes no If yes, ll out both Part A below and Part B on the next page. If no, ll out Part B on the next page.

HIN

Part A: Health Insurance You Have Now

1. Policyholder name Social security number* Policy type (Check one.) Policy number Employer or union name Policyholder contribution to premium costs (Complete one.) $ per week $ per quarter $ per month individual couple (two adults) Insurance company name dual (one adult, one child) Group number (if known) family Policy start date ____ / ____ / ____ Date of birth / /

TRICARE Insurance type (Check one.) employer or union subsidized (employer or union pays some or all of the insurance cost) other federal or state subsidized (government pays some or all of the insurance cost) student health insurance through school nonsubsidized, like self-employment or COBRA (policyholder pays total insurance cost) Medical Security Program Names of covered family members Insurance coverage (Check all that apply.) doctors visits and hospitalizations catastrophic only vision only pharmacy only dental only

If you have long-term-care insurance, send a copy of the policy. * Required, if obtainable and one has been issued, whether or not this person is applying.

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2. Policyholder name Social security number* Policy type (Check one.) Policy number Employer or union name Policyholder contribution to premium costs (Complete one.) $ per week $ individual couple (two adults) Insurance company name dual (one adult, one child) Group number (if known) family

Date of birth

Policy start date ____ / ____ / ____

per quarter $

per month

TRICARE Insurance type (Check one.) employer or union subsidized (employer or union pays some or all of the insurance cost) other federal or state subsidized (government pays some or all of the insurance cost) student health insurance through school nonsubsidized, like self-employment or COBRA (policyholder pays total insurance cost) Medical Security Program Names of covered family members Insurance coverage (Check all that apply.) doctors visits and hospitalizations catastrophic only vision only pharmacy only dental only

If you have long-term-care insurance, send a copy of the policy. * Required, if obtainable and one has been issued, whether or not this person is applying.

Part B: Subsidized Health Insurance You May Be Eligible For

Are you or any member of your family in one of the uniformed services? yes no If yes, ll out the section below. (The uniformed services are the Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Services, National Oceanic and Atmospheric Administration, and the National Guard or Reserves.) 1. Name: Active Duty? 2. Name: Active Duty? yes no Retiree? yes no Reserves? yes no Medal of Honor? yes no yes no Retiree? yes no Reserves? yes no Medal of Honor? yes no

SIA NAT

Have you or any member of your family served in the U.S. military or can you be considered a dependent of someone who has served in the U.S. military? Yes, I have served. Name: Yes, I am a dependent of someone who has served. Name: No, I am neither a veteran nor a dependent.

American Indian/Alaska Native

Certain American Indians and Alaska Natives may not have to pay MassHealth premiums and copays. Are you or any member of your family who is applying a federally recognized American Indian or Alaska Native who is eligible to receive or has received services from an Indian health-care provider or from a non-Indian health-care provider through referral from an Indian health-care provider? yes no If yes, name of person(s):

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General instructions for lling out the Injury, Illness, Disability, or Accommodation, Absent Parent, and U.S. Citizenship/National Status and Immigration Status sections below
The HIV section is optional. You must answer all questions in each of the three sections after the HIV section.
HIV

HIV Information (optional)

MassHealth may give benets to people who are HIV positive who might not otherwise be eligible. Do you or any family member who is HIV positive want to apply for these benets? yes no If yes, ll out this section. Send proof of income, U.S. citizenship/national status and identity, or qualied alien status to see if you can get benets for up to 60 days while we wait for you to send us proof of your HIV-positive status. For more information, see the MassHealth Member Booklet. Name(s):

Injury, Illness, Disability, or Accommodation

Do you or any family member have an injury, illness, or disability (including a disabling mental-health condition) that has lasted or is expected to last for at least 12 months? (If legally blind, answer yes.) yes no Do you or any family member need health care because of an accident or injury? yes no Do you or any family member applying for MassHealth require a reasonable accommodation because of a disability or injury? yes no If you answered yes to any of these three questions, you must ll out Supplement A (the blue sheet).

Absent Parent
Has any child in the household been adopted by a single parent or has a parent who is deceased or unknown? yes no Does any child in the family have a parent who does not live with you who is not included in the previous question? yes no If you answered yes to either of these questions, you must ll out Supplement B (the yellow sheet).
QAC

U.S. Citizenship/National Status and Immigration Status

The U.S. citizenship/national status of parents does not affect the eligibility of their children.

U.S. Citizens
For applicants born in Massachusetts who want help getting proof of their U.S. citizenship, please ll out Supplement D (the red sheet). For applicants born outside Massachusetts who want help getting proof of their U.S. citizenship, MassHealth may be able to help you. Please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

Persons who are not U.S. citizens/nationals

If you or any other family member applying for MassHealth or Commonwealth Care ts any of the immigration status codes on Supplement C (the orange sheet), numbered 1 through 17, you must ll out Supplement C. If you or any other family member applying for benets does not t any of the immigration status codes on Supplement C (the orange sheet), numbered 1 through 17, you or that family member may get only one or more of the following: MassHealth Limited, Healthy Start, CMSP, or the Health Safety Net. You do not have to ll out Supplement C. Note: A social security number is not required for approval for MassHealth Limited. We will not match the names of applicants for MassHealth Limited with any other agency including the Department of Homeland Security (DHS). You do not need to send proof of immigration status. MassHealth Limited pays for emergency services only. See the MassHealth Member Booklet for more information. List below the names of family members who want to get only one or more of the following: MassHealth Limited, Healthy Start, CMSP, or the Health Safety Net. Name(s): Name(s):

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Please read this page carefully, then sign and date the bottom of the page.

This is an application for MassHealth, the Childrens Medical Security Plan (CMSP), Healthy Start, Commonwealth Care, and the Health Safety Net.
I give permission for my current and former employers and health insurers to release to MassHealth, the Commonwealth Health Insurance Connector Authority (the Health Connector), and the Health Safety Net (administered by the Executive Ofce of Health and Human Services) any and all information they have about my health-insurance coverage and health-insurance coverage for members of my family group. This includes, but is not limited to, information about policies, premiums, coinsurance, deductibles, and covered benets that are, may be, or should have been available to me or members of my family group. I understand that MassHealth may enroll me in available employer-sponsored health insurance if that insurance meets the criteria for MassHealth payment of premium assistance. I and my spouse understand that our employers may be notied and billed, in accordance with the regulations of the Health Safety Net, with regard to any services I and my spouse and any of our dependents may get from hospitals or community health centers that are paid for by the Health Safety Net. If I or any members of my family are found to be eligible for assistance through MassHealth, the Health Connector, or the Health Safety Net, I give permission to MassHealth, the Health Connector (Commonwealth Care), or the Health Safety Net to get any records or data: (1) to prove any information given on this application and any supplements, or other information I give once I am a member; (2) to document medical services claimed or provided; and (3) to support continued eligibility. I understand that if I am aged 55 or older, MassHealth may be able to get back money from my estate after I die. Under current practice, this does not apply to Commonwealth Care. I understand that if I or any members of my family are in an accident, or we are injured in some other way, and get money from a third party because of that accident or injury, we will need to use that money to repay: (1) MassHealth (for MassHealth, CMSP, and Healthy Start) or the Health Connector or my current health insurer (for Commonwealth Care) for certain medical services provided (For MassHealth, these certain medical services are explained in the MassHealth Member Booklet. For Commonwealth Care, these certain medical services must have been provided to me by my health insurer.); or (2) the Health Safety Net for medical services reimbursed for me and any family members by the Health Safety Net. I also understand that I must tell MassHealth (for MassHealth, CMSP, and Healthy Start), my health insurer (for Commonwealth Care), or the Health Safety Net in writing, within 10 calendar days, or as soon as possible, if I le any insurance claim or lawsuit because of an accident or injury to me or any family members applying for benets. I understand that if I or any members of my family are eligible for MassHealth, CMSP, Healthy Start, Commonwealth Care, or the Health Safety Net, I must tell MassHealth of any changes in my or my familys income or employment, family size, health-insurance coverage, health-insurance premiums, and immigration status, or of changes in any other information I gave on this application and any supplements within 10 calendar days of learning of the change. I also understand that by signing below, I give permission to MassHealth to go after and collect third-party payments for medical care and medical support from the parent of any child under age 19 who is applying for benets. If I or any members of my family are eligible for MassHealth or CMSP, I understand that I may have to pay a premium set by MassHealth. I also understand that if I fail to pay the premium, MassHealth may refer my past due balance to the State Intercept Program (SIP). If I am a certain American Indian or Alaska Native eligible for MassHealth Family Assistance, I may not have to pay any premiums under MassHealth Family Assistance. If I or any members of my family are eligible for Commonwealth Care, I understand that I may have to pay a premium set by the Health Connector. I certify that I have read or have had read to me the information on this application, including any supplements and instruction pages attached to it, and the information in the MassHealth Member Booklet, and that I understand my rights and responsibilities. I further certify under penalty of perjury that the information on this application and any supplements, including those submitted with this application as well as any other supplements, forms, or documents that may be submitted to or required by MassHealth, is correct and complete to the best of my knowledge. If you are acting on behalf of someone in lling out this application and any supplements, the enclosed MassHealth Eligibility Representative Designation Form must also be lled out and sent back with this application. Your signature on this application and any supplements as an eligibility representative certies that the information on this application and any supplements, including those submitted with this application as well as any other supplements, forms, or documents that may be submitted to or required by MassHealth, is correct and complete to the best of your knowledge. If you think MassHealths decision about whether you are eligible is wrong, you have the right to appeal or le a grievance. If you are denied benets, you will get information about how to appeal a MassHealth decision and also how to le a grievance about any Health Safety Net decision. The head of household, all persons aged 18 or older, and all parents of any age who have children living with them who are applying for MassHealth, CMSP, Healthy Start, Commonwealth Care, or the Health Safety Net must read this page carefully, and sign and date below. If you are signing below as an eligibility representative, a lled-out MassHealth Eligibility Representative Designation Form must also be submitted.

X
Signature of applicant or eligibility representative Print name Print name Date Date Go to Supplement A Please go to the next page

X
Signature of applicant or eligibility representative

Clear entire form.

Supplement A:
Injury, Illness, Disability, or Accommodation Questions
Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth

Leave this page blank if you answered NO to all the injury, illness, disability, and accommodation questions on page 6. Fill out this page if you answered YES to any of the three injury, illness, disability, and accommodation questions on page 6.
PDI DDU

Injury, Illness, or Disability

Fill out this section for you or any family member who has an injury, illness, or disability (including a disabling mental-health condition). Name Does this person have an injury, illness, or disability (including a disabling mental-health condition) that has lasted or is expected to last yes no for at least 12 months? Does this person get money from Social Security for a disability? yes no Has this person ever gotten Supplemental Security Income (SSI)? yes no Is this person legally blind? yes no If yes, send a copy of the Certicate of Blindness.

ACC

Accommodations for People with a Disability or Injury

Do you or any family member applying for MassHealth have any special circumstances or a disability? Name If yes, please check all that apply. low vision blind deaf developmentally disabled intellectually disabled physically disabled hard of hearing other ______________________________ As a result, does the person you identied need support services/reasonable accommodations to communicate with MassHealth? yes no If yes, please check all that apply. text telephone (TTY) large-print publications American Sign Language interpreter Video Relay Service (VRS) Communication Access Real-time Translations (CART) publications in Braille assistive listening device publications in electronic format other (please describe) ____________________________________ yes no

TPR

Accident or Injury
Fill out this section if you or any family member need health care because of an accident or injury. You must answer all three questions. Name yes no Are you or any family member applying because of an accident or injury that someone else might be responsible for? Do you or any family member have an injury, illness, or disability that was caused by someone else, or that could be covered by someone elses insurance or the family members own insurance, other than health insurance (like homeowners or auto insurance)? yes no Has a lawsuit, a workers compensation claim, or an insurance claim for an accident or injury been led for you or any family member who is applying? yes no If you need more space, please use the back of this page.

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Back to page 6

Supplement B:
Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth

Absent-Parent Questions and Assignment of Rights

Do not ll out this supplement if you answered NO to both of the absent-parent questions on page 6. Fill out this supplement only if you answered YES to either of the absent-parent questions on page 6. Please read Part A of Supplement B before you ll out Parts B, C, and D. You must sign Part E.

Absent Parent
Part A: Cooperation
To get MassHealth for you and a child who is living with you, you must cooperate with the Child Support Enforcement Division of the Massachusetts Department of Revenue (DOR) to establish paternity and enforce a medical-support order, unless you have Good Cause not to cooperate. You must also assign your rights for medical support to MassHealth. Cooperation means that you may have to give information about the identity, location, and employment of the absent parent, appear for appointments with DOR staff and the Court, submit to paternity testing, give information, and take any other action necessary to help DOR in establishing paternity, and establishing, changing, or enforcing a child medical-support order. Good Cause is a legal term that means if you cooperated by giving us information about the absent parent, it would not be in the best interests of the child for any of the reasons listed in Part CGood Causebelow. If you think that you have Good Cause for not cooperating, ll out Part CGood Causebelow, and do not ll out Part D Absent-Parent Informationon the next page. If you do not want to make a Good Cause claim, and you do not cooperate by lling out Part DAbsent-Parent Informationon the next page, your MassHealth eligibility could be affected. To get MassHealth only for the child who is living with you and not for yourself, you do not have to cooperate with DOR, assign your rights for medical support to MassHealth, or give information about the absent parent. Also, if a pregnant family member is applying for benets for an unborn child, you do not need to give us information about the absent parent of the unborn child at this time. This means that you do not have to ll out Part B, C, D, or E of this supplement for that unborn child. Please read the next paragraph about child-support-enforcement services. Even if you are applying for MassHealth only for the child who is living with you, you can ask for child-support-enforcement services if you want help getting the absent parent to pay for health insurance or child support for the child. To do this, you can call DOR at 1-800-332-2733, or go to www.mass.gov/dor and click on Child Support Enforcement. The childs MassHealth coverage will not be affected if you choose to ask for these services or not. If you ask for these services, you will have to cooperate with DOR.

Part B: Names of children who have been adopted by a single parent or have a parent who is deceased or unknown
Please list the name(s) of the child or children who have been adopted by a single parent or have a parent who is deceased or unknown. Name Name Name Name

If all of the children in the household are named in this section, go to Part E. Otherwise, go to Part C.

Part C: Good Cause

Is there any reason (Good Cause) not to help us get medical support from an absent parent? yes no If yes, list the name(s) of the child or children whose absent parent(s) you do not want to give us information about, and check one of the boxes below for the reason that applies to the child or children. If no, ll out Part DAbsent-Parent Informationon the next page. Names: Cooperation could result in serious physical or emotional harm to a family member or his or her child, or the applicant or member. Adoption of the child is in process. The child was a result of sexual abuse or assault. Names: Cooperation could result in serious physical or emotional harm to a family member or his or her child, or the applicant or member. Adoption of the child is in process. The child was a result of sexual abuse or assault.

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Supplement B:
Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth

Absent-Parent Questions and Assignment of Rights

Absent Parent (cont.)

Part D: Absent Parent Information (if known)
1. Name Address Telephone number ( Relationship to child: ) mother father other: Is there a medical-support order? yes no Drivers license number* Social security number* Date of birth / / Gender M F

Names of children of this absent parent Name and address of absent parents employer

2. Name Address Telephone number ( Relationship to child: ) mother father

Social security number*

Date of birth

Gender

Is there a medical-support order? other:

yes

no Drivers license number*

Names of children of this absent parent Name and address of absent parents employer

*Required, if obtainable and one has been issued.

Part E: Signature
I am the parent with whom the child lives (custodial parent or legal guardian) and I certify under penalty of perjury that the information in this supplement is correct and complete to the best of my knowledge. I also understand that by signing below I assign my rights and give permission to MassHealth and DOR to go after medical support from the absent parent (named in Part D) of any child under age 19 who is living with me and applying for MassHealth. I also agree to cooperate with MassHealth and DOR in this process, as explained in Part A Cooperation of this supplement.

X
Signature of custodial parent or guardian** Print name **Required, only if you are applying for yourself and the child who is living with you. Date

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Supplement C:
Questions for Immigrants
Commonwealth of Massachusetts EOHHS EOHHS www.mass.gov/masshealth
QAC

Leave this page blank if all family members who are applying are U.S. citizens/nationals. Fill out this page if any family member is applying for MassHealth or Commonwealth Care and is not a U.S. citizen/national. 1.

Are you or any family member on active duty, or a veteran of the United States Armed Forces with an honorable discharge, or did you or any family member serve under U.S. command during World War II or in Vietnam? yes no If yes, you may stop here, but list applicable family members. Names: If no, go to the next question.

2.

Are you or any family member the spouse, widow or widower, or dependent of a person on active duty or a veteran described above? If yes, you may stop here, but list applicable family members. Names: If no, go to the next question.

yes

no

3.

Are you or any family member a victim of domestic abuse and no longer living with the abuser? If yes, you may stop here, but list applicable family members. Names: If no, you must ll out the rest of this page (Immigration Status).

yes

no

Immigration Status

Fill out the chart below for each member of the family who is not a U.S. citizen/national and who is applying for MassHealth or Commonwealth Care. List all immigration statuses that have applied to each person since that person entered the U.S. Send copies of both sides of all immigration cards (or other documents that show immigration status). See the MassHealth Member Booklet for a more complete description of immigration statuses. Use these codes to describe your immigration status in the chart below. 15. Victim of severe forms of 12. Refugee 4. Amerasian admitted pursuant to 8. Deportation withheld trafficking* 13. Person with a visitor visa/other Section 584 of Public Law 100-202 9. Legal permanent resident 14. Person residing under color of law 16. Iraqi Special Immigrant 5. Granted asylum 10. Native American with at least 17. Afghan Special Immigrant (PRUCOL), including temporary 6. Conditional entrant 50% American Indian blood protected status and applicant 7. Cuban/Haitian entrant born in Canada * Human trafficking for prostitution asylum 11. Granted parole or involuntary servitude Name Status codes (List all that apply.) a b c d a Date status awarded b c d U.S. entry date / / / / / / / / / / / /

QAC

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Supplement D:
Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth

Help Getting Proof of U.S. Citizenship for Persons Born in Massachusetts

RVS

Fill out one section below for EACH family member who is applying, was born in Massachusetts, and wants help getting proof of his or her U.S. citizenship through the Massachusetts Registry of Vital Records and Statistics. Note: When lling out the sections below, be sure to print each family members name as it would appear on his or her birth certicate. Applicants current last name Applicants last name at time of birth (if different) Date of birth Massachusetts hospital name Mothers/Coparents last name (at time of applicants birth) Fathers/Coparents last name (at time of applicants birth) Applicants current last name Applicants last name at time of birth (if different) Date of birth Massachusetts hospital name Mothers/Coparents last name (at time of applicants birth) Fathers/Coparents last name (at time of applicants birth) Applicants current last name Applicants last name at time of birth (if different) Date of birth Massachusetts hospital name Mothers/Coparents last name (at time of applicants birth) Fathers/Coparents last name (at time of applicants birth) First First Gender at time of birth (if different) Massachusetts city of birth First First First First Gender at time of birth (if different) Massachusetts city of birth First First First First Gender at time of birth (if different) Massachusetts city of birth First First MI MI Mothers maiden name Suffix (ex., Jr.) MI MI MI MI Mothers maiden name Suffix (ex., Jr.) Suffix (ex., Jr.) Suffix (ex., Jr.) MI MI MI MI Mothers maiden name Suffix (ex., Jr.) Suffix (ex., Jr.) Suffix (ex., Jr.) MI MI Suffix (ex., Jr.) Suffix (ex., Jr.)

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