Fillable Printable MassHealth Mail and Fax Cover Sheet

MassHealth Mail and Fax Cover Sheet

is facsimile transmittal may contain information that is privileged, condential, or exempt from disclosure under applicable law. It is

intended for the use of only the individual or department to which it is addressed. If you are not the recipient or the employee or the agent

responsible for the delivery of this transmittal to the intended recipient, please notify the sender by telephone at the above number and

destroy the attached documents. Anyone other than the intended recipient is hereby notied that any dissemination, distribution, or copying

of this communication is strictly prohibited.

Please allow time for MassHealth to receive your documents and process them. If your benets have ended

and you need medical services, call the MEC at 1-888-665-9993 (TTY: 1-888-665-9997 for people with

partial or total hearing loss).

Use this address or fax if you are already getting MassHealth benets. is includes eligibility reviews for

individuals and families of any age who live in the community or in a long-term-care facility.

Use this address or fax if you are applying for health benets. is is for individuals and families of any age

who live in the community.

MassHealth Enrollment Center (MEC)

P.O. Box 1231

Taunton, MA 02780

Fax: 617-887-8777

MassHealth Central Processing Unit

P.O. Box 290794

Charlestown, MA 02129

Fax: 617-887-8799

Do NOT photocopy cover sheets. For bar codes to work, cover sheets must be originals, not copies. Use

a separate cover sheet for each household. Do NOT use the same cover sheet to send items for more than

one household. If you are sending this aer hearing from MassHealth, send the requested items to the fax

number or post oce box on the request.

Head of Household Information

Name: ______________________________

____

___

Soc. Sec. No: ____________________________

___

Date of birth: ________________________________

MassHealth ID No. (if applicable):

___________________________________________

No. of pages (including cover sheet): ______

____

Date: _________________________________

___

Sender

Name: __________________________________

Phone No: ____________________

_________

Name of Facility (if applicable):

_______________________________

___

________________________________

___

____

MassHealth Mail/Fax Cover Sheet

MFCS (01/12)

Fax or Mail

Info for

MEMBERS

Fax or Mail

Info for

APPLICANTS

Important

Message

Please print clearly. Use this cover sheet when mailing or faxing documents to MassHealth.