Form Masshealth – Fill Out and Use This PDF

The MassHealth Adult Disability Supplement is a critical document for residents of Massachusetts with disabilities seeking health coverage through MassHealth. It is meticulously designed to gather comprehensive information about an individual's disability, medical and mental health history, providers, and their daily living activities to assess eligibility for disability-based benefits. Everyone indicated by their MassHealth application as having a disability must complete this supplement with care, ensuring that all sections are filled out to facilitate a speedy eligibility determination. For detailed guidance on completing the form and to take the next step towards securing your health benefits, click the button below.

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Form Masshealth PDF Details

Embarking on the journey of completing the MassHealth Adult Disability Supplement can be overwhelming. This essential document, stemming from the Commonwealth of Massachusetts' Executive Office of Health and Human Services, serves as a key piece in the application process for individuals seeking MassHealth based on disability. The form meticulously gathers detailed information on an applicant's medical and mental health history, treatment providers, work history, educational background, daily activities, and more. It plays a critical role in the evaluation process by UMass Disability Evaluation Services, determining eligibility for benefits swiftly and efficiently. Applicants are urged to provide comprehensive details about their health care providers, including doctors, therapists, and clinics, to facilitate a thorough review. Moreover, the supplement inquires about one's living situation, capabilities in performing daily tasks, language proficiency, educational attainment, and recent employment history, aiming to paint a complete picture of the applicant's current state. The instruction to provide detailed information, coupled with the necessity of a Medical Release Form for each listed provider, underscores the importance of accuracy and completeness in the submission. This document is not merely a form but a gateway to accessing crucial health benefits, demanding careful attention and thoroughness from every applicant.

Question	Answer
Form Name	Form Masshealth
Form Length	16 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	4 min
Other names	MassHealth Adult Disability Supplement

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MassHealth

Adult Disability Supplement

Commonwealth of Massachusetts | Executive Office of Health and Human Services

Instructions for Completing the Supplement

You have indicated on your MassHealth application that you have a disability. Disability standards require that the disability has lasted or is expected to last at least 12 months. UMass Disability Evaluation Services (DES) will review your disability application for MassHealth. It is very important that you complete this Disability Supplement.

To get MassHealth based on your disability, you need to tell us about

•your medical and mental health providers. These may include doctors, psychologists, therapists, social workers, physical therapists, chiropractors, hospitals, health centers, and clinics from whom you receive or have received treatment; and

•yourself: your work history for the past 15 years, your educational background, and your daily activities.

Completing the Disability Supplement will give us this information and will help us make a quick decision.

Please read the following instructions before beginning.

•Print, or write clearly and complete the supplement to the best of your ability.

•Sign and date a Medical Release Form for each medical and mental health provider you list on the supplement.

•After you have filled out the supplement, submit it to

Disability Evaluation Services / UMASS Medical DES

P.O. Box 2796

Worcester, MA 01613-2796

DES will ask for your medical and treatment records from the providers you have listed. If you have any of your medical records, please send a copy with this form. If more information or tests are needed, a member of DES will get in touch with you. Your eligibility will be determined more quickly if all items on the supplement are filled in.

This is not an application for medical benefits. If you have not already completed a MassHealth application, you must fill one out in addition to this form. If you have any questions about how to apply, please call 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

If you need help with this form, you can call the UMass Disability Evaluation Services (DES) Help Line at 1-888-497-9890.

Fill in every section of this form. If you do not ﬁll in every section, we may not be able to decide if you are disabled.

Information about you

MALE

FEMALE

Last name First name Middle initial

Social security number

Street address

City

Apt. #

State	Zip code		Date of birth (mm/dd/yyyy)
		—

Home phone

Cell phone

Work/other phone

We may need to schedule a doctor’s appointment for you. What are the best times for you to go to an appointment? Please check all the times that are good for you.

Any time is ok	Monday a.m.	Tuesday a.m.		Wednesday a.m.
	Monday p.m.	Tuesday p.m.		Wednesday p.m.
Did you apply for Social Security or SSI/SSDI benefits?			yes	no
If yes, did you see a doctor for an exam?
Doctor’s name

Thursday a.m.	Friday a.m.
Thursday p.m.	Friday p.m.

Date of exam _____/_____/________

MADS-A/MR COMBO (Rev. 04/15)

Please go to the next page.

PART 1 Your health problems

List and describe all your medical and mental health problems. If you are getting treatment for the problem, please tell us what kind of treatment.

List your medical and/or	Describe the symptoms or pain related to each health	Date when	Medications/
mental health problems.	problem.	problem started.	treatment

Depression	Very tired all the time. Hard to get out of bed in the morning.	April 2010	None
	I cry a lot during the day. I can’t control when I cry.

Back pain	Pain starts in my lower back and goes down my leg	June 2007	Skelexin

Did any of your health problems start because of an accident or injury? If yes, please explain.

yes

PART 2 Information about all your medical and mental health providers

Did you get any health care in the past year?

yes

If yes, please list every medical and mental health provider that treated you for any of your health problems since they started. A medical or mental health provider may include a doctor, psychologist, therapist, social worker, physical therapist, chiropractor, hospital, health center, and clinic from which you receive treatment. You can write on a separate piece of paper if you run out of space.

If you are receiving treatment from only one facility, list only that facility.

Name of medical and mental health providers	Reason for visit	Was this visit
		in the past year?

		yes	no

		yes	no

		yes	no

		yes	no

Please fill out a Medical Records Release Form for each medical and mental health provider on this list. Be sure to sign and date each form. These release forms are at the end of this packet. If you need more copies of the Medical Release Form, call a MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled) or download the form at www.mass.gov/masshealth.

PART 3 Where you live

Where do you live? (Check one.)

House or apartment

Group home

Other (describe)

State facility

Nursing home

Rehabilitation hospital

Homeless

MADS-A/MR COMBO (Rev. 04/15)

2	Please go to the next page.

PART 4 What you can do

Are you	right handed?	left handed?
Do your medical or mental health problems make it hard for you to do any of the following things?

		If yes,	If yes, please explain below.
		check here

Dress and bathe			My shoulder pain makes it hard for me to lift my arm over my head. This
Dress and bathe			makes it hard to put on shirts or wash my hair.
			makes it hard to put on shirts or wash my hair.

Do regular housework			When I am depressed, I don’t care if my house is clean.

Sit

Stand

Walk

Bend

Reach

Lift

Remember

See

Hear

Use your hands

Dress and bathe

Do regular housework

Listen to music

Watch TV

Use a computer

Read

Talk on the phone

Go outside

Go for a walk

Go shopping

Go to the doctor

Visit friends and family

Go to school

Handle money/use an ATM

Drive a car

Take a bus, train, or taxi

Play sports

Other (describe)

MADS-A/MR COMBO (Rev. 04/15)

3	Please go to the next page.

PART 5	Your language

Do you speak English?		yes	no	limited
Do you understand English?			yes	no	limited
Do you read English?		yes	no	limited
Do you write English?		yes	no	limited
What is your first language?
Can you read in your first language?				yes	no	limited
Can you write in your first language?				yes	no	limited

PART 6

School

Check the highest grade of school you finished.

Associate’s degree

GED

Bachelor’s degree

What year did you finish this

grade?

Where did you go to school?

Did you repeat any grades?

yes

Were you in special education?

yes

not sure

Did you finish more than 12 years of school?

yes

If yes, please list your degree and major

Did you get any other training?

yes

If yes, please fill out the

sections below.

Type of training

Year

Finished

Certified/Licensed

Building trades

yes

Electronics

yes

Cooking

yes

Auto mechanics

yes

Computers

yes

Hairdressing

yes

Cosmetology

yes

Nurse’s aide

yes

Secretarial

yes

Other (describe)

yes

PART 7

Your work

Do you work now?

yes

If no, when did you stop working? Date ___ /___ /______

Did any of your medical or mental health conditions cause problems at work? If yes, plesae explain.

yes

MADS-A/MR COMBO (Rev. 04/15)

4	Please go to the next page.

Part 7. Your work (continued)

List all your jobs from the last 15 years. Do the best that you can. If you do not know the exact dates, write your best guess.

Start with the job you have now or your last job. Add a piece of paper if you need more space. You can attach a resume if you have one. Here is a sample.

Job title Packer

Dates worked: From (Month/Year) March 2012

To (Month/Year) May 2012

Job duties (List everything you did.) Put three golf balls into a small box. Packed 24 small boxes into a case. Sealed the case with packing tape. Loaded cases onto a platform.

How many hours did you work each week? 40			How much did you make an hour? $9.00/hour

Reason for leaving Moved

Job title		Dates worked: From (Month/Year)			To (Month/Year)

Job duties (List everything you did.)

How many hours did you work each week?			How much did you make an hour?

Reason for leaving

Job title		Dates worked: From (Month/Year)			To (Month/Year)

Job duties (List everything you did.)

How many hours did you work each week?			How much did you make an hour?

Reason for leaving

Job title		Dates worked: From (Month/Year)			To (Month/Year):

Job duties (List everything you did.)

How many hours did you work each week?			How much did you make an hour?

Reason for leaving

Check each of the things you do in your job. If you do not work, check each thing you did in your last job.
Doing paperwork	Using a computer	Assembling		Operating machines	Filing
Serving people	Counting & packing	Construction		Using phone	Driving a car or truck
Moving things	Cleaning	Using office machines		Using cash register	Driving a forklift
Using power tools	Using hand tools	Other (please describe)

Circle the number of hours you do each thing in your job. If you do not work, circle the number of hours you did each thing in your last job.

Activity	Hours in a Day

Walk or stand	0	1	2	3	4	5	6	7	8
Sit	0	1	2	3	4	5	6	7	8
Reach	0	1	2	3	4	5	6	7	8

Check the weight you lift or carry most.
Less than 10 lbs.	10 lbs.	20 lbs.	25 lbs.	50 lbs.	100 lbs.	More than 100 lbs.
Check the heaviest weight you lift.
Less than 10 lbs.	10 lbs.	20 lbs.	25 lbs.	50 lbs.	100 lbs.	More than 100 lbs.

MADS-A/MR COMBO (Rev. 04/15)

5	Please go to the next page.

PART 8 Your comments

Use this space to write any additional information about why you cannot work.

PART 9 Your signature and rights

THIS SECTION MUST BE COMPLETED.

You have the right to privacy. The information on this form is confidential. All possible precautions will be taken to ensure your privacy rights.

Signature of Applicant/Guardian/Authorized Representative

Date _____/_____/________

Authorized Representative

If this form is being filled out by someone with the legal authority to act on behalf of the applicant/member (such as the parent of an adult disabled child or spouse, an authorized representative, or a legal guardian), give us the following information.

Signature of person filling out this form

Print name

Authority of person filling out this form on behalf of the applicant/member

DES may send copies of notices to the authorized representative. This area does not authorize release of medical records.

You may choose an authorized representative to help you with some or all of the responsibilities of applying for or getting health benefits.

You can do this by filling out a MassHealth Authorized Representative Designation Form (ARD). To ask for an ARD form, 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).

HELP WITH THIS FORM

Did you need help to fill out this form? If yes, why did you need help?

yes

REMINDER

Did you remember to

complete a medical release form for each medical or mental health provider listed on page 2? sign all medical release forms?

sign this Disability Supplement above?

include a completed and signed Authorized Representative Designation Form (ARD) if needed?

MADS-A/MR COMBO (Rev. 04/15)

6	Please go to the next page.

MassHealth

Medical Records Release Form

Commonwealth of Massachusetts | Executive Office of Health and Human Services | www.mass.gov/masshealth

MassHealth Disability Evaluation Service

This MassHealth Medical Records Release Form helps us get medical information from your health-care provider so that the MassHealth Disability Evaluation Service (DES) can make a disability determination.

Please read the instructions carefully before you fill out this form. If you leave any sections of this form blank, this permission will not be valid, and the health-care provider will not be able to share your information with the MassHealth DES. If the health-care provider does not share medical information with the MassHealth DES, we will not be able to make a disability determination.

General instructions for ﬁlling out the Medical Records Release Form

You must follow these instructions when filling out the medical records to the MassHealth DES if you do not fill disability determination.

Medical Records Release Forms. The health-care providers will not send out the forms the right way. We need copies of medical records to make a

1.Sign and date a Medical Records Release Form for each doctor, hospital, health center, clinic, or other health-care provider you listed in the Disability Supplement.

2.All signatures must be in ink and must be originals. No copies or stamps of signatures are permitted.

3.Only one signature may appear on a line.

4.If this form is for a child younger than age 18, one parent or legal guardian must sign for the child.

SECTION I

Permission is given for the health-care provider listed in Section II to share the medical information listed in Section III about

with the MassHealth DES.

(Please print name of applicant or member.)

SECTION II

Please print the name of the health-care provider that may share medical information with the MassHealth DES.

Name of doctor, health center, or other health-care provider

Street address

City, state, zip

Phone ( )

SECTION III

The health-care provider listed in Section II above may share the following information with the MassHealth DES to determine eligibility for MassHealth benefits.

All medical records or other information about my treatment, hospitalization, or outpatient care for conditions including

psychological/psychiatric impairments		how impairments affect activities of daily living and ability to work
AIDS/HIV		drug and alcohol use
other (please describe)

Check here if you do not want the health-care provider to share information about AIDS/HIV status.

Check here if you do not want the health-care provider to share information about drug or alcohol use.

MADS-MR (Rev. 04/15)

(continued on back)

SECTION IV

Any medical information that the health-care provider releases to the MassHealth Disability Evaluation Service (DES) will continue to be protected by federal privacy laws.

This permission to release medical information to the MassHealth DES ends six months from the date you sign this release form, unless you have cancelled permission in writing before then.

I understand that I may cancel this permission at any time by sending a letter to the health-care provider I listed in Section II.

I understand that even if I cancel this permission, the health-care provider I listed in Section II cannot take back any information that it shared with the MassHealth DES when it had my permission to do so.

I also understand that my decision whether to give the health-care provider permission to share medical information with the MassHealth DES is voluntary. However, I also understand that if I do not give permission to the health-care provider to share medical information with the MassHealth DES, the MassHealth DES will not be able to make a disability determination, and the decision about eligibility for MassHealth benefits will be made without consideration of any disability claimed.

SECTION V

Signature of applicant/member			Date

Print name of applicant/member		Phone (	)

Street address		Date of birth

City/Town	State	Zip code	—

If this form is being filled out by someone who has the legal authority to act on behalf of the applicant/member

(such as the parent of a minor child, an eligibility representative, or a legal guardian), please give us the following information.

Signature of person filling	out this form

Print name	Date

Authority of person filling	out this form to act on behalf of the applicant/member

Please give us a copy of the document that gives this person the authority to act on behalf of the applicant/member.

MassHealth will send you back a copy of this signed Medical Records Release Form for you to keep for your records. You can also ask for another copy of this signed Medical Records Release Form at any time by contacting MassHealth at the following address.

Disability Evaluation Services

UMASS Medical DES

P.O. Box 2796

Worcester, MA 01613-2796

MassHealth

Medical Records Release Form

Commonwealth of Massachusetts | Executive Office of Health and Human Services | www.mass.gov/masshealth

MassHealth Disability Evaluation Service

General instructions for ﬁlling out the Medical Records Release Form

You must follow these instructions when filling out the medical records to the MassHealth DES if you do not fill disability determination.

Medical Records Release Forms. The health-care providers will not send out the forms the right way. We need copies of medical records to make a

1.Sign and date a Medical Records Release Form for each doctor, hospital, health center, clinic, or other health-care provider you listed in the Disability Supplement.

2.All signatures must be in ink and must be originals. No copies or stamps of signatures are permitted.

3.Only one signature may appear on a line.

4.If this form is for a child younger than age 18, one parent or legal guardian must sign for the child.

SECTION I

Permission is given for the health-care provider listed in Section II to share the medical information listed in Section III about

with the MassHealth DES.

(Please print name of applicant or member.)

SECTION II

Please print the name of the health-care provider that may share medical information with the MassHealth DES.

Name of doctor, health center, or other health-care provider

Street address

City, state, zip

Phone ( )

SECTION III

The health-care provider listed in Section II above may share the following information with the MassHealth DES to determine eligibility for MassHealth benefits.

All medical records or other information about my treatment, hospitalization, or outpatient care for conditions including

psychological/psychiatric impairments		how impairments affect activities of daily living and ability to work
AIDS/HIV		drug and alcohol use
other (please describe)

Check here if you do not want the health-care provider to share information about AIDS/HIV status.

Check here if you do not want the health-care provider to share information about drug or alcohol use.

MADS-MR (Rev. 04/15)

(continued on back)

SECTION IV

Any medical information that the health-care provider releases to the MassHealth Disability Evaluation Service (DES) will continue to be protected by federal privacy laws.

This permission to release medical information to the MassHealth DES ends six months from the date you sign this release form, unless you have cancelled permission in writing before then.

I understand that I may cancel this permission at any time by sending a letter to the health-care provider I listed in Section II.

SECTION V

Signature of applicant/member			Date

Print name of applicant/member		Phone (	)

Street address		Date of birth

City/Town	State	Zip code	—

If this form is being filled out by someone who has the legal authority to act on behalf of the applicant/member

(such as the parent of a minor child, an eligibility representative, or a legal guardian), please give us the following information.

Signature of person filling	out this form

Print name	Date

Authority of person filling	out this form to act on behalf of the applicant/member

Please give us a copy of the document that gives this person the authority to act on behalf of the applicant/member.

Disability Evaluation Services

UMASS Medical DES

P.O. Box 2796

Worcester, MA 01613-2796

How to Edit Form Masshealth Online for Free

This PDF editor makes it easy to fill in forms. There's no need to perform much to manage MassHealth Adult Disability Supplement forms. Just follow the next actions.

Step 1: You can press the orange "Get Form Now" button at the top of the page.

Step 2: Now you're on the form editing page. You may enhance and add text to the form, highlight specified content, cross or check certain words, insert images, put a signature on it, erase unneeded areas, or eliminate them altogether.

These particular areas are what you will need to prepare to get your ready PDF document.

portion of empty spaces in Form Masshealth

The software will require you to submit the If you need help with this form, Information about you Last name, Female, Male, Street address, Apt, City State Zip code Date of birth, Home phone Cell phone Workother, We may need to schedule a doctors, Please check all the times that, Any time is ok, Monday am, Tuesday am, Wednesday am, and Thursday am part.

You could be required some relevant particulars to be able to prepare the PART Your health problems, List and describe all your medical, List your medical andor mental, Back pain, Describe the symptoms or pain, Date when problem started April, Medications treatment None, June, and Skelexin section.

Within the section Did any of your health problems, yes, If yes please explain, PART Information about all your, Did you get any health care in the, yes, If yes please list every medical, If you are receiving treatment, Name of medical and mental health, Reason for visit, Was this visit in the past year, yes, yes, yes, and yes, write down the rights and obligations of the sides.

Fill in the file by checking the following fields: Please fill out a Medical Records, PART Where you live, Where do you live Check one, House or apartment, Group home, State facility, Nursing home, Rehabilitation hospital, Homeless, Other describe, MADSAMR COMBO Rev, and Please go to the next page.

Step 3: Hit the button "Done". Your PDF file can be exported. It's possible to upload it to your pc or send it by email.

Step 4: Make copies of the document. This may protect you from future challenges. We cannot watch or publish your data, thus feel comfortable knowing it will be protected.

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