Families in Massachusetts navigating the process of applying for state health plans, like MassHealth, must sometimes complete additional forms, like the MassHealth Absent Parent form. This necessity arises when an application lists one or more children with a single custodial parent in the household, flagging the potential involvement of a noncustodial parent. The form plays a crucial role in ensuring that children receive medical support from both parents, whenever possible. It requires detailed information about the noncustodial parent and must be completed by the custodial parent or legal guardian. The goal is to facilitate the cooperation with the Child Support Enforcement Division of the Massachusetts Department of Revenue, aiming to secure medical support from noncustodial parents. However, it acknowledges that there may be valid reasons, known as good cause reasons, for not being able to provide this information or for the custodial parent’s noncooperation, which could include safety concerns or the absence of information about the noncustodial parent. Importantly, while a custodial parent's eligibility for MassHealth may be affected by non-compliance with this requirement, the child’s access to benefits will not be jeopardized. Additionally, this form opens the door to other possible financial benefits for the child, beyond health insurance, by establishing paternity. Thus, this form is more than a bureaucratic requirement; it's a critical step in ensuring that children have access to the fullest possible range of support and benefits.
| Question | Answer |
|---|---|
| Form Name | Masshealth Absent Parent Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | non custodial parent form ncp 1, masshealth non custodial parent form, form ncp 1, custodial form pdf |
NONCUSTODIAL PARENT FORM
Commonwealth of Massachusetts | Executive Office of Health and Human Services
Instructions
You’re getting this form because you recently applied for a state health plan such as MassHealth. On that application, you listed one or more children in your household with only one custodial parent. This indicates that the child(ren) may have a noncustodial parent. A noncustodial parent is a parent who does not live with their child.
This form must be filled out and signed by the custodial parent or legal guardian of any child listed on the application for health care coverage. You must provide the requested information for each child who has a noncustodial parent.
To get MassHealth, you agree to cooperate with MassHealth and the Child Support Enforcement Division of the Massachusetts Department of Revenue (DOR) in trying to get medical support for your children from their noncustodial parents unless you have a good cause reason not to cooperate. You can review the list of good cause reasons under the “Children Listed on the Application” section of this form. Cooperating means, but is not limited to
Telling the DOR if there are any changes to the information you gave us about yourself or the other parent. Appearing as a witness at court or other proceeding.
Appearing at paternity testing appointments and other appointments if necessary.
Providing DOR with copies of documents that are needed for your case, if requested, such as birth or marriage certificates, court orders, and divorce orders.
Taking any other reasonable steps to identify the father, to get medical support and payments, and to help us go after liable third parties.
Your eligibility could be affected if you do not fill out this form in its entirety and do not meet the exceptions described below.
Please fax or mail this form to:
Health Insurance Processing Center
PO Box 4405
Taunton, MA 02780
Fax: (857)
Important
MassHealth will not deny or stop your child’s MassHealth benefits if you do not cooperate, but your own eligibility may be impacted. Even if you are not required to identify the father (establish paternity), knowing who the father is may lead to financial benefits for your child. These benefits may include Social Security dependents’ benefits, pension benefits, veterans benefits, and possible rights of inheritance.
If you are not eligible for MassHealth, you can still get child support enforcement services. These services can help to get the noncustodial parent to provide medical support or child support for the child. To do this, call the Department of Revenue (DOR) at (800)
Noncustodial Parent Information
Please provide the following information on the application for each child who has a noncustodial parent, including unborn or expected children. We have provided space for three children and three noncustodial parents. If you need more room, please make a copy of this form or use a separate piece of paper.
1 |
Please go to the next page |
Unborn or Expected Children
Are you currently pregnant? If you are applying for benefits for an unborn child, you do not need to give us information about the noncustodial parent of the unborn child at this time.
I am currently pregnant AND I am not married to the father of this child.
How many babies are you expecting? _________ What is your expected due date? _________________
NOTE: You do not have to provide information for this child’s noncustodial parent while you are pregnant. If the noncustodial parent is not in the household at the end of your pregnancy, you will need to tell MassHealth about the noncustodial parent at that time.
Name of Child #1
First name |
Middle name |
Last name |
Do any of the following good cause reasons apply to this child?
Adoption of this child is in process.
This child was born as a result of sexual abuse or assault.
Cooperation, as defined on page 1, is not in the best interest of this child. (For example, cooperation could result in serious physical or emotional harm to me or the child or both.)
I adopted this child as a single parent.
The noncustodial parent of this child has died.
I do not know who the noncustodial parent of this child is.
If you checked any of the boxes above, you do not have to provide information for this child’s noncustodial parent. Please provide noncustodial parent information for any other child(ren) and sign at the end of this form.
Name of noncustodial parent for Child #1
First name
I do not know
Middle name |
Last name |
Noncustodial parent’s relationship to child |
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Date of birth (mm/dd/yyyy) |
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Telephone number
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Employer name and address
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Does the noncustodial parent have insurance that covers dependents?
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No
I do not know
If yes, please provide the following information.
Policyholder name
Insurance company
Policy number
Group number
Has a court issued an order for the noncustodial parent to provide health insurance for the child?
If yes, where and when was the order issued?
Yes
No
I do not know
I do not know
Has a court issued an order for the noncustodial parent to provide health insurance for you, the custodial parent? |
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Name of Child #2
First name |
Middle name |
Last name |
Do any of the following good cause reasons apply to this child?
Adoption of this child is in process.
This child was born as a result of sexual abuse or assault.
Cooperation, as defined on page 1, is not in the best interest of this child. (For example, cooperation could result in serious physical or emotional harm to me or the child or both.)
I adopted this child as a single parent.
The noncustodial parent of this child has died.
I do not know who the noncustodial parent of this child is.
If you checked any of the boxes above, you do not have to provide information for this child’s noncustodial parent. Please provide noncustodial parent information for any other child(ren) and sign at the end of this form.
Name of noncustodial parent for Child #2
First name
I do not know
Middle name |
Last name |
Is this the same noncustodial parent named for Child #1 above?
Yes
No If yes, skip the rest of this section. Make sure to sign this form.
Noncustodial parent’s relationship to child |
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Gender of child |
Date of birth (mm/dd/yyyy) |
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Telephone number
I do not know
Employer name and address
I do not know
Does the noncustodial parent have insurance that covers dependents?
Yes
No
I do not know
If yes, please provide the following information.
Policyholder name
Insurance company
Policy number
Group number
Has a court issued an order for the noncustodial parent to provide health insurance for the child?
Yes
No
I do not know
If yes, where and when was the order issued?
I do not know
Has a court issued an order for the noncustodial parent to provide health insurance for you, the custodial parent?
Yes
No
I do not know
If yes, where and when was the order issued?
I do not know
3 |
Please go to the next page |
Name of Child #3
First name |
Middle name |
Last name |
Do any of the following good cause reasons apply to this child?
Adoption of this child is in process.
This child was born as a result of sexual abuse or assault.
Cooperation, as defined on page 1, is not in the best interest of this child. (For example, cooperation could result in serious physical or emotional harm to me or the child or both.)
I adopted this child as a single parent.
The noncustodial parent of this child has died.
I do not know who the noncustodial parent of this child is.
If you checked any of the boxes above, you do not have to provide information for this child’s noncustodial parent. Please provide noncustodial parent information for any other child(ren) and sign at the end of this form.
Name of noncustodial parent for Child #3
First name
I do not know
Middle name |
Last name |
Is this the same noncustodial parent named for Child #1 |
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Child #2 |
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above? If so, check the appropriate child(ren) and skip the rest of this |
section. If the noncustodial parent of Child #3 is not the parent of either Child #1 or Child #2, complete the rest of this section. Make sure to sign this form.
Noncustodial parent’s relationship to child |
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Gender of child |
Date of birth (mm/dd/yyyy) |
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Social security number |
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Driver’s license number |
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Address |
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Telephone number
I do not know
Employer name and address
I do not know
Does the noncustodial parent have insurance that covers dependents?
If yes, please provide the following information.
Yes
No
I do not know
Policyholder name
Insurance company
Policy number
Group number
Has a court issued an order for the noncustodial parent to provide health insurance for the child?
If yes, where and when was the order issued?
Yes
No
I do not know
I do not know
Has a court issued an order for the noncustodial parent to provide health insurance for you, the custodial parent?
Yes
No
I do not know
If yes, where and when was the order issued?
I do not know
Signature
I certify under penalty of perjury that I am the custodial parent or legal guardian of the minor child(ren) listed on this form, that I have provided all the information I have or can reasonably get, and that the information in this form is correct and complete to the best of my knowledge.
Signature of custodial parent or legal guardian
Print name
Date
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