Please rate Form Masshealth 2025-05
The parts are your health issues, providers, language, school, work for the past 5 years, comments, and signature and rights.
Providers: Sign and date an Authorization to Release Protected Health Information Form for each medical and mental health provider you list on the supplement.
Medical records: If you have any of your medical records, please send a copy with this form.
Authority: If this form is being filled out by someone with the legal authority to act on behalf of the applicant, that individual must sign and attach legal paperwork.
Speed: Completely filling out this supplement will speed up the process of determining your eligibility.
| Question | Answer |
|---|---|
| Form Name | MADS-A-MR |
| Form Length | 16 pages |
| Fillable? | Yes |
| Fillable fields | 310 |
| Avg. time to fill out | 52 min |
| Edition | 2025-05 |
| Issuing agency | Commonwealth of Massachusetts Executive Office of Health and Human Services |
| Where to send | Disability Evaluation Services (DES), PO Box 2796, Worcester, MA 01613-2796 |
| Other names | MADS-A-MR, MassHealth Adult Disability Supplement, MassHealth disability supplement, MADS |
| Official source | MADS-A-MR (Rev 2025-05), Massachusetts Executive Office of Health and Human Services |
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Please rate Form Masshealth 2025-05
