Absent Parent Form PDF Details

The Commonwealth of Massachusetts provides a specific form for applicants or members of MassHealth where children are involved, and there is an absent parent from the household, namely, the Absent-Parent Questions and Assignment of Rights form. This document is vital for those seeking MassHealth coverage for children under circumstances where a parent is not present due to various reasons, such as absence, death, or when the parent's identity remains unknown. Before applicants fill out the detailed sections, including personal information and specifics about the child or children in question, Part A instructs on the necessity of cooperation with the Child Support Enforcement Division of the Massachusetts Department of Revenue to establish paternity and enforce medical-support orders, barring any legally supported reasons for non-cooperation known as "Good Cause." Those applying need not cooperate if seeking health benefits solely for the child and not themselves, with specific conditions for pregnant family members applying for an unborn child. The form also outlines the protocol for those claiming Good Cause for not providing absent parent information, which directly influences MassHealth eligibility. Moreover, the form allows for the possibility of seeking child-support-enforcement services independently of MassHealth application processes, emphasizing the importance of accurate and complete information, as certified by the signing guardian under the penalty of perjury, essentially binding the guardian to aid in obtaining medical support from the absent parent where applicable.

QuestionAnswer
Form NameAbsent Parent Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmass health absent parent form, non custodial parent form ncp 1, parent non custodial form for masshealth, absent patent no custodial parent

Form Preview Example

Commonwealth of Massachusetts

EOHHS

www.mass.gov/masshealth

Absent-Parent Questions and Assignment of Rights

For ofi ce use only

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

Please print clearly. Please read Part A before you ll out Parts B, C, and D. If you need more space to nish any section, please use a separate piece of paper (include your name and MassHealth ID or social security number) and attach it to this form. You must sign Part E.

Head of Household

 

Last name

 

 

First name

MI

 

Date of birth

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

MassHealth ID (or SSN if no MassHealth ID)

 

 

 

Telephone number

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street address

 

 

 

 

City

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing address (if di erent from street address or if living in a shelter )

homeless

 

 

 

 

 

 

 

 

 

 

 

 

City

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Children

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Last name

 

 

First name

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth

/

/

MassHealth ID (or SSN if no MassHealth ID)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Last name

 

 

First name

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth

/

/

MassHealth ID (or SSN if no MassHealth ID)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Last name

 

 

First name

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth

/

/

MassHealth ID (or SSN if no MassHealth ID)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Absent Parent

PART A

ABS

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 sta 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 C—Good Cause—on the next page. If you think that you have Good Cause for not cooperating, ll out Part C—Good Cause—on the next page, and do not ll out Part D—Absent-Parent Information—on the next page.

If you do not want to make a Good Cause claim, and you do not cooperate by lling out Part D—Absent-Parent Information—on the next page, your MassHealth eligibility could be aected.

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.”The child’s MassHealth coverage will not be aected if you choose to ask for these services or not. If you ask for these services, you will have to cooperate with DOR.

AP-1 (REV. 10/12)

OVER

Absent Parent (cont.)

PART B

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

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 D—Absent-Parent Information—below. Name(s):

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. Name(s):

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.

PART D

1.Name Address

Social security number*

Date of birth

/

/

 

 

 

Gender M F

Telephone number (

)

 

 

Is there a medical-support order?

yes no

 

 

 

 

 

 

 

Relationship to child:

mother

father

other:

 

Driver’s license number*

 

 

 

 

 

Names of children of this absent parent

 

 

 

 

 

 

 

 

 

Name and address of absent parent’s employer

 

 

 

 

 

 

 

 

 

 

 

2.Name Address

Social security number*

Date of birth

/

/

Gender M F

Telephone number (

)

 

 

Is there a medical-support order?

yes no

 

 

 

 

 

 

 

Relationship to child:

mother

father

other:

 

Driver’s license number*

 

 

 

 

 

Names of children of this absent parent

 

 

 

 

 

 

 

 

 

Name and address of absent parent’s 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

Date

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AP Rev , AP Rev , and Over of masshealth non custodial form

3. The following segment is about Please list the names of the child, Name Name, If all of the children in the, PART CGood Cause, Is there any reason Good Cause not, yes, If yes list the names of the child, If no fi ll out Part DAbsentParent, Names, Cooperation could result in, Names, Cooperation could result in, PART DAbsentParent Information if, Name Social security number Date, and Address - type in every one of these blank fields.

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