Masshealth Mail/Fax Cover Sheet - Free Download
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Masshealth Mail/Fax Cover Sheet
Masshealth Mail/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.
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