Fillable Printable Sample Masshealth Fax Cover Sheet

Sample Masshealth Fax Cover Sheet

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Health Coverage

Mail/Fax Cover Sheet

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

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

Do NOT photocopy the cover sheet containing the barcode. For barcodes to work, the sheet with the barcode

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

same two-page cover sheet to send items for more than 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 Service Center at 1-800-841-2900.

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

If your benefits have ended and 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 facsimile transmittal may contain information that is privileged, confidential, or exempt from disclosure under applicable

law. It is intended for the use of only the individual or department to whom 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 notified

that any dissemination, distribution, or copying of this communication is strictly prohibited.

HC-CS (02/15)

Type of Document

Where to Send

» New paper applications for subsidized

(assistance with paying) health coverage,

including Health Connector (ConnectorCare

plans and those seeking premium tax

credits), MassHealth, or HSN coverage

» Eligibility verification documents for

MassHealth and the Health Connector

Subsidized applications and verifications for

eligibility should be sent to:

Health Insurance Processing Center

P.O. Box 4405

Taunton, MA 02780

NEW Fax: 857-323-8300

» New paper applications for unsubsidized

(no assistance with paying) health insurance

through the Health Connector

» Closed Enrollment verification for Health

Connector plan

Unsubsidized applications and verifications for

IDP and Closed Enrollment should be sent to:

Massachusetts Health Connector

133 Portland Street, 1st Floor

Boston, MA 02114-1707

Fax: 617-887-8745

» MassHealth long-term-care applications

and Supplement A + Buy-In applications

These applications should be 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

MassHealth

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Health Coverage Mail/Fax Cover Sheet

Applicant/Member Information

Please print clearly. Use this cover sheet plus the first page containing 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):

____________________________________________

Reference ID No. (if applicable):

___________________________________________

Applicant/Member:

____________________________________________

Sender

Name: ______________________________________

Phone No: ___________________________________

Name of Facility (if applicable):

_____________________________________________

This facsimile transmittal may contain information that is privileged, confidential, 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 notified that any dissemination, distribution, or copying of this communication is strictly prohibited.

Number of pages (including both cover sheets): _______________