MassHealth Mail or Fax Cover Sheet

Health Coverage
Mail/Fax Cover Sheet
Last four digits of Hea d 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 wo rk, t he sheet wit h the b arcode
must be an or iginal, not a copy. Use a separate two-page cover sheet for each household. Do NOT use the
s ame two-pa ge cove r sheet to send items for mo re t han one household.
Always mail or fax verifica tions to the addr ess or fax on the letter requesting the verifications. If you are not sure
where to fax or mail documents, contact the MassHealth Customer Serv ices Center at 1-800-841-2900.
Please allow time for the Health Connector or MassHealth to r eceive your documents and p r o cess them.
If your be nefits have end ed 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 facs im i l e tr a ns m ittal may c o ntain informati o n that is pr i v ileged, co n fidential, or ex e m p t f r om disclosure under applicable
la w. It is i nt e n d e d for t h e us e o f only the i ndivi d ual or de p a rt men t to w hom it is a d dress ed. If y o u ar e not t he recipient or the
employee or the agent responsible for the delivery of this transmittal to the intended recipient, please no tify t he s ender by
telephone at the above number and destroy the attached document s. Anyone other than th e intended recipient is hereby notified
that an y dissemination, distribut ion, or copying of thi s communi cation is stri ctly prohibited.
HC-CS (05/14)
Type of Document Where to Send
All new paper applica tions for subsidized
(assistance with paying) health coverage,
including Health Connector (ConnectorCare plans
and those s eeking premium tax credits) ,
MassHealth, or HSN coverage
Subsidized applica tions s ho uld b e sent to :
Health Insurance Processing Center
P.O. Box 4405
Taunton, MA 02780
Fax: 617-887-8770
All new paper applications for unsubsidized (no
ass i st ance with payi ng) hea lth i nsurance thro ugh
the Health Co nnector
Unsubsidized applications should be sent to:
Massachusetts Health Connecto r
133 Portland Street, 1st Floor
Boston, MA 02114-1707
Fax: 877-623-2155
MassHealth long-term-care applications and
Supplement A + Buy-In applications
These app lic a tions should b e sent to :
Cent ra l Proce s s ing Unit
P.O. Box 290794
Charlesto wn, MA 02129
Fax: 617-887-8799
Important
Message
Fax or Mail
Information
for Health
Connector
or MassHe alt h
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MassHealth Mail or Fax Cover Sheet PDF

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