Fillable Printable MassHealth Mail or Fax Cover Sheet

MassHealth Mail or Fax Cover Sheet

Health Coverage

Mail/Fax Cover Sheet

Last four digits of Head of Household’s Social Security N umber: ___ ___ ___ ___ OR

Head of Household initials: __ __ and DOB (MM/DD/YYYY): ____/____/________

Do NOT photocopy the cover sheet containing the barcode. For barcodes to work, the s heet with the b arcode

must be an ori ginal, not a copy. Use a separate two-page cover sheet for each household. Do NOT use the

same two-p age cover she et t o send items for more t han one household.

Always mail or fax verifications to the address or fax on the letter requesting the verifications. If you are not sure

where to fax or mail documents, contact the MassHealth Customer Services Center at 1-800-841-2900.

Please allow time for the Health Connector or MassHealth to receive your documents and process them.

If your be nefits have end ed an d you need medical services, call the MEC at 1-888-665-9993

(TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled).

This f ac sim i l e tr a ns m ittal may contai n i n for mation tha t is pr ivile g e d, co nfide n t ial, or ex e m p t fr om disclosure under applicable

law . I t is i nt e n d e d for t h e us e o f only the indiv idual or depart ment to whom it is addres s e d . I f y o u ar e not t he recipi ent or the

employee or the agent responsible for the delivery of this transmittal to the intended recipient, please no tify the s ender by

te lephone at the above number and destr oy the attached documents. An yone othe r than the intended recipient is hereby notified

that any dissemination, distribut ion, or c opying of this communication is st ri ctly prohibited .

HC-CS (05/14)

Type of Document Where to Send

All new pap e r applications for subsidized

(assistance with paying) health coverage,

including Health Connector (ConnectorCare plans

and tho se se eking premium tax credit s ),

MassHealth, or HSN coverage

Subsidized ap plications should be sent to:

Health Insurance Processing Center

P.O. Box 4405

Taunton, MA 02780

Fax: 617-887-8770

All new paper applications for unsubsidized (no

assi st ance with payi ng) health insur ance through

the Health Connector

Unsubsidized applications should be sent to:

Massachusetts Health Connector

133 Portland Street, 1st Floor

Boston, MA 02114-1707

Fax: 877-623-2155

MassHealth long-term-care applications and

Supple ment A + Buy-In app lic a tions

These a pplica tions should b e sent to :

Central Processing Unit

P.O. Box 290794

Charlestown, MA 02129

Fax: 617-887-8799

Important

Message

Fax or Mail

Information

for Health

Connector

or MassHeal th

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Health Coverage Mail/Fax Cover Sheet

Applicant/Member Information

Please print clearly. Use this cover sheet, plus t he first page c ontaining the barcode, when mailing or faxing

documents to the Health Connector or MassHealth.

Head of Household Information

Name: ______________________________________

Soc. Sec. No: ________________________________

Date of birth: _________________________________

MassHealth ID No. (if applicable):

____________________________________________

Applicant/Member:

____________________________________________

Sender

Name: ______________________________________

Phone No: ___________________________________

Name of Fac ility (if applicable):

_____________________________________________

This f ac simil e tr a ns m ittal ma y contai n in f or matio n that is privileged, c o n f i dentia l, or ex em pt from discl osure 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 th e agen t

res p o ns ible for the deli v ery of t his transmitt al to the int ended recipient, pl ease n ot ify the sender by telephone at the above number and

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

of this communication is strictly p rohibited.

Nu mber of pages (includ ing both cover sheets): _______________

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