Form Masshealth PDF Details

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.

QuestionAnswer
Form NameForm Masshealth
Form Length16 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min
Other names

Form Preview Example

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.

Thursday a.m.

Friday a.m.

 

 

Monday p.m.

Tuesday p.m.

 

Wednesday p.m.

Thursday p.m.

Friday 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

 

 

 

 

 

Date of exam _____/_____/________

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

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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

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

 

 

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)

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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

 

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)

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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.

 

 

 

 

 

 

 

 

 

 

 

 

K

1

 

2

3

4

5

6

7

8

Associate’s degree

 

 

 

9

10

11

12

 

GED

 

 

 

 

Bachelor’s degree

 

 

 

 

What year did you finish this

grade?

 

 

 

 

Where did you go to school?

 

 

 

 

 

 

 

 

Did you repeat any grades?

 

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

Were you in special education?

yes

 

no

not sure

 

 

 

 

 

 

 

 

 

Did you finish more than 12 years of school?

yes

no

 

 

 

 

 

 

 

 

 

If yes, please list your degree and major

 

 

 

 

 

 

 

 

 

 

 

 

Did you get any other training?

 

yes

 

no

 

 

 

 

 

 

 

 

 

 

 

 

If yes, please fill out the

sections below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of training

 

 

 

 

 

 

 

 

Year

 

 

Finished

 

Certified/Licensed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Building trades

 

 

 

 

 

 

 

 

 

 

 

yes

no

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Electronics

 

 

 

 

 

 

 

 

 

 

 

 

yes

no

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cooking

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes

no

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Auto mechanics

 

 

 

 

 

 

 

 

 

 

 

yes

no

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Computers

 

 

 

 

 

 

 

 

 

 

 

 

yes

no

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hairdressing

 

 

 

 

 

 

 

 

 

 

 

 

yes

no

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cosmetology

 

 

 

 

 

 

 

 

 

 

 

 

yes

no

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nurse’s aide

 

 

 

 

 

 

 

 

 

 

 

 

yes

no

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Secretarial

 

 

 

 

 

 

 

 

 

 

 

 

yes

no

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (describe)

 

 

 

 

 

 

 

 

 

 

 

yes

no

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 7

 

 

Your work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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

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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)

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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

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?

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

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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

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

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

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

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

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