For individuals and families navigating the healthcare landscape in Massachusetts, the Financial Information Request (FIR) form plays a pivotal role, especially for applicants of MassHealth, the state's Medicaid program. This document, emerging from the bustling offices of the Commonwealth of Massachusetts Executive Office of Health and Human Services, serves as a bridge between personal financial data and potential healthcare benefits. Located at the bustling MassHealth Enrollment Center in Springfield, the process to wield this form is straightforward yet crucial. Applicants or their spouses must furnish details regarding their bank accounts by completing the form, a step indispensable for the completion of the MassHealth application process. Notably, the form caters to those who might face difficulties obtaining their bank records, including unsolicited fees, offering a pathway to acquire these documents without cost. The design of the FIR form is user-friendly, necessitating basic information like names, addresses, social security numbers, and specifics about the financial institution. Furthermore, it prompts the applicant to indicate not only the account numbers and relevant time periods but also the preferred destination for the dispatched information. The choice to route the information directly to the applicant or the MassHealth Enrollment Center underscores a flexibility in handling personal financial data. Completing this sequence—filling out, signing, and delivering the form—is a regulatory compliance with M.G.L. c. 118E, § 23A, ensuring the provision of deposit and withdrawal records by the financial institution at no charge. This seemingly simple form is a critical step in accessing healthcare services, underpinning the broader efforts to streamline health coverage applications and promote financial transparency within the context of healthcare assistance programs.
| Question | Answer |
|---|---|
| Form Name | Fir Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | f i r copy image, fir copy sample, blank fir copy, fir form pdf download |
he Commonwealth of Massachusetts Executive Oice of Health and Human Services www.mass.gov/masshealth
MassHealth Enrollment Center 333 Bridge Street Springield, MA 01103
TTY:
Fax:
|
|
|
Financial Information Request |
|
|||
Name: |
|
|
Social security number: |
|
|
||
Address: |
|
|
City/Town/Zip: |
|
|||
Name of inancial institution: |
|
|
|
|
|
||
Address: |
|
|
City/Town/Zip: |
|
|
||
You or your spouse have applied for MassHealth. You must get a copy of your bank accounts to us so we can complete the application process. If you do not have your account records, you can get them from your bank.
Sometimes banks charge a fee to get these records. You can get them at no cost with this form.
You need to complete one form for each bank where you have accounts.
•Complete the top of this form (PLEASE PRINT your name, address, and social security number and the name and address of the inancial institution).
•In Section 1, list the account number and time period that you need the bank records for.
•In Section 2, tell the bank where you want the information sent (to you or to the MassHealth Enrollment Center listed above).
•Sign and date the form before you give it to your bank.
•Bring or mail the form to the bank.
Pursuant to M.G.L. c. 118E, § 23A, please provide, without charge, the deposit and withdrawal records for the accounts and time periods listed below for the
Section 1 |
|
|
Account number: |
|
Time period: |
Account number: |
|
Time period: |
Account number: |
|
Time period: |
Section 2
Within two weeks of your receipt of this request, please send that information to:
the
the MassHealth Enrollment Center listed above.
Signature of MassHealth Applicant/Member or Spouse |
|
Date |
|
MassHealth Signature |
|
|
|