Form Masshealth is a process by which you can apply for health insurance through the Massachusetts Health Insurance Connector. The program offers affordable health care coverage to residents of Massachusetts, and there are several different plans available depending on your needs and budget. In this blog post, we will provide an overview of the application process and outline the benefits of enrolling in Form Masshealth.
You may find info about the type of form you need to submit in the table. It can show you how much time you will require to finish form masshealth, exactly what fields you will have to fill in and several additional specific details.
Question | Answer |
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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
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
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
If you need help with this form, you can call the UMass Disability Evaluation Services (DES) Help Line at
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. #
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Zip code |
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Date of birth (mm/dd/yyyy) |
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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. |
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Any time is ok |
Monday a.m. |
Tuesday a.m. |
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Wednesday a.m. |
Thursday a.m. |
Friday a.m. |
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Monday p.m. |
Tuesday p.m. |
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Wednesday p.m. |
Thursday p.m. |
Friday p.m. |
Did you apply for Social Security or SSI/SSDI benefits? |
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no |
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If yes, did you see a doctor for an exam? |
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Doctor’s name |
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Date of exam _____/_____/________ |
1 |
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 |
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Depression |
Very tired all the time. Hard to get out of bed in the morning. |
April 2010 |
None |
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I cry a lot during the day. I can’t control when I cry. |
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Back pain |
Pain starts in my lower back and goes down my leg |
June 2007 |
Skelexin |
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Did any of your health problems start because of an accident or injury? If yes, please explain.
yes
no
PART 2 Information about all your medical and mental health providers
Did you get any health care in the past year?
yes
no
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 |
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in the past year? |
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no |
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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
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
2 |
Please go to the next page. |
PART 4 What you can do
Are you |
right handed? |
left handed? |
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Do your medical or mental health problems make it hard for you to do any of the following things? |
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If yes, |
If yes, please explain below. |
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check here |
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Dress and bathe |
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My shoulder pain makes it hard for me to lift my arm over my head. This |
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makes it hard to put on shirts or wash my hair. |
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Do regular housework |
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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)
3 |
Please go to the next page. |
PART 5 |
Your language |
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Do you speak English? |
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no |
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Do you understand English? |
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Do you read English? |
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no |
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Do you write English? |
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What is your first language? |
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Can you read in your first language? |
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Can you write in your first language? |
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no |
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PART 6 |
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School |
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Check the highest grade of school you finished. |
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K |
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Associate’s degree |
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GED |
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Bachelor’s degree |
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What year did you finish this |
grade? |
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Where did you go to school? |
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Did you repeat any grades? |
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Were you in special education? |
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not sure |
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Did you finish more than 12 years of school? |
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no |
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If yes, please list your degree and major |
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Did you get any other training? |
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If yes, please fill out the |
sections below. |
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Type of training |
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Year |
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Certified/Licensed |
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Building trades |
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Electronics |
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Cooking |
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Auto mechanics |
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Computers |
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Hairdressing |
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Cosmetology |
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Nurse’s aide |
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Secretarial |
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Other (describe) |
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PART 7 |
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Your work |
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Do you work now? |
yes |
no |
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
no
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 |
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How much did you make an hour? $9.00/hour |
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Reason for leaving Moved |
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Job title |
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Dates worked: From (Month/Year) |
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To (Month/Year) |
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Job duties (List everything you did.) |
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How many hours did you work each week? |
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How much did you make an hour? |
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Reason for leaving |
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Job title |
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Dates worked: From (Month/Year) |
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To (Month/Year) |
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Job duties (List everything you did.) |
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How many hours did you work each week? |
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How much did you make an hour? |
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Reason for leaving |
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Dates worked: From (Month/Year) |
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To (Month/Year): |
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Job duties (List everything you did.) |
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How many hours did you work each week? |
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How much did you make an hour? |
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Reason for leaving |
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Check each of the things you do in your job. If you do not work, check each thing you did in your last job. |
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Doing paperwork |
Using a computer |
Assembling |
Operating machines |
Filing |
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Serving people |
Counting & packing |
Construction |
Using phone |
Driving a car or truck |
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Moving things |
Cleaning |
Using office machines |
Using cash register |
Driving a forklift |
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Using power tools |
Using hand tools |
Other (please describe) |
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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 |
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Walk or stand |
0 |
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Sit |
0 |
1 |
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Reach |
0 |
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7 |
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Check the weight you lift or carry most. |
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Less than 10 lbs. |
10 lbs. |
20 lbs. |
25 lbs. |
50 lbs. |
100 lbs. |
More than 100 lbs. |
Check the heaviest weight you lift. |
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Less than 10 lbs. |
10 lbs. |
20 lbs. |
25 lbs. |
50 lbs. |
100 lbs. |
More than 100 lbs. |
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
HELP WITH THIS FORM
Did you need help to fill out this form? If yes, why did you need help?
yes
no
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?
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
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
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
1.Sign and date a Medical Records Release Form for each doctor, hospital, health center, clinic, or other
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
with the MassHealth DES.
(Please print name of applicant or member.)
SECTION II
Please print the name of the
Name of doctor, health center, or other
Street address
City, state, zip
Phone ( )
SECTION III
The
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 |
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AIDS/HIV |
drug and alcohol use |
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other (please describe) |
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Check here if you do not want the
(continued on back)
SECTION IV
Any medical information that the
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
I understand that even if I cancel this permission, the
I also understand that my decision whether to give the
SECTION V
Signature of applicant/member |
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Print name of applicant/member |
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Phone ( |
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Street address |
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Date of birth |
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City/Town |
State |
Zip code |
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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 |
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Print name |
Date |
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Authority of person filling |
out this form to act on behalf of the applicant/member |
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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
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
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
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
1.Sign and date a Medical Records Release Form for each doctor, hospital, health center, clinic, or other
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
with the MassHealth DES.
(Please print name of applicant or member.)
SECTION II
Please print the name of the
Name of doctor, health center, or other
Street address
City, state, zip
Phone ( )
SECTION III
The
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 |
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AIDS/HIV |
drug and alcohol use |
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other (please describe) |
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Check here if you do not want the
(continued on back)
SECTION IV
Any medical information that the
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
I understand that even if I cancel this permission, the
I also understand that my decision whether to give the
SECTION V
Signature of applicant/member |
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Date |
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Print name of applicant/member |
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Phone ( |
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Street address |
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Date of birth |
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City/Town |
State |
Zip code |
— |
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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 |
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|
|
Print name |
Date |
||
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|
|
|
Authority of person filling |
out this form to act on behalf of the applicant/member |
||
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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
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
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
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
1.Sign and date a Medical Records Release Form for each doctor, hospital, health center, clinic, or other
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
with the MassHealth DES.
(Please print name of applicant or member.)
SECTION II
Please print the name of the
Name of doctor, health center, or other
Street address
City, state, zip
Phone ( )
SECTION III
The
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
(continued on back)
SECTION IV
Any medical information that the
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
I understand that even if I cancel this permission, the
I also understand that my decision whether to give the
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
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
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
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
1.Sign and date a Medical Records Release Form for each doctor, hospital, health center, clinic, or other
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
with the MassHealth DES.
(Please print name of applicant or member.)
SECTION II
Please print the name of the
Name of doctor, health center, or other
Street address
City, state, zip
Phone ( )
SECTION III
The
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
(continued on back)
SECTION IV
Any medical information that the
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
I understand that even if I cancel this permission, the
I also understand that my decision whether to give the
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
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
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
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
1.Sign and date a Medical Records Release Form for each doctor, hospital, health center, clinic, or other
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
with the MassHealth DES.
(Please print name of applicant or member.)
SECTION II
Please print the name of the
Name of doctor, health center, or other
Street address
City, state, zip
Phone ( )
SECTION III
The
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
(continued on back)
SECTION IV
Any medical information that the
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
I understand that even if I cancel this permission, the
I also understand that my decision whether to give the
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