Masshealth Fax Cover Sheet - Free Download
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UCP REVIEW TEAM
FAX Cover Sheet
Head of Household (HOH) Information
Facility Name: ___________________________
Sender’s Phone No: ______________________
Sender’s Name: _________________________
Soc. Sec. No: _______________________________
Please include this cover sheet when faxing or mailing any documents to the MassHealth UCP Review
Place a checkmark ( 9 ) in the appropriate space below identifying the attached verification(s).
____ UCP Eligibility Review Form
____ Other ___________________________________________________________________________
This facsimile transmittal may contain information that is privileged, confidential, or exempt from disclosure under
applicable law 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.