Masshealth Form Crf 1 PDF Details

Access to healthcare services in Massachusetts is widely supported by MassHealth, the state's comprehensive health insurance program. A crucial aspect of maintaining the integrity and trust in this system involves the careful screening of healthcare providers. This is where the MassHealth Criminal Offender Record Information (CORI) Request Form, officially known as the CRF-1 form, comes into play. Designed to ensure that participating or applying providers do not have a history that could jeopardize the welfare of patients, the form requires providers to consent to a criminal record check. This check is confined to conviction and pending criminal case data, emphasizing that not all criminal records necessarily lead to disqualification from the program. Applicants must verify the truthfulness and completeness of the information they provide under the potential consequences of civil penalties or criminal prosecution for any misrepresentation. Essential details such as personal identification, contact information, and consent for a background check are encapsulated in this document, highlighting the commitment of the Commonwealth of Massachusetts Executive Office of Health and Human Services to uphold both safety and quality in healthcare delivery.

QuestionAnswer
Form NameMasshealth Form Crf 1
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescrf 1 masshealth cori request form

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Commonwealth of Massachusetts

Executive Office of Health and Human Services

www.mass.gov/masshealth

Criminal Offender Record Information (CORI) Request Form

MassHealth Customer Service has been certified by the Criminal History Systems Board for access to conviction and pending criminal case data. As a participating or applying MassHealth provider, I understand that a criminal record check will be conducted for conviction and pending criminal case information only and that it will not necessarily disqualify me.

I hereby certify under the pains and penalties of perjury that the information on this form and any attachments that I have provided, has been reviewed and is true, accurate, and complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein. (Signature and date stamps, or the signature of anyone other than the provider or applicant, are not acceptable.)

Signature of provider or applicant

Last name, first name, middle name (Please print.)

Maiden name or alias

 

 

 

 

Place of birth

(if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth

 

 

Social security number

 

 

 

 

 

 

 

 

(Required)

 

 

 

 

 

 

 

 

 

 

 

 

Mother’s maiden name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Former address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender:

 

M

 

F

Height

 

Weight

 

Eye color

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State driver’s license number

NOTE: Please attach a copy of your driver's licence so that MassHealth can validate the information you provided above.

CRF-1 (REV. 10/12)

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