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Get Ma Mads-a 2015

MassHealth will send you back a copy of this signed Medical Records Release Form for you to keep for your records. You can also request another copy of this signed Medical Records Release Form at any time by contacting MassHealth at the following address. You can do this by filling out a MassHealth Eligibility Representative Designation Form ERD. To request an ERD form call MassHealth Customer Service at 1-800-841-2900 TTY 1-800-497-4648 for people with partial or total hearing loss. Be sure to sign and date each form. These release forms are at the end of this packet. If you need more copies of the Medical Release Form call a MassHealth Enrollment Center at 1-888-665-9993 TTY 1-888-665-9997 for people with partial or total hearing loss or download the form at www. Print type or write clearly and complete the supplement to the best of your ability. Sign and date a Medical Release Form for each medical and mental health provider you list on the supplement. After you have filled out the supplement submit it to your MassHealth Enrollment Center. The supplement will be sent to DES for review. This permission to release medical information to the MassHealth Disability Evaluation Service ends six months from the date you sign this release form unless you have cancelled permission in writing before then. I understand that I may cancel this permission at any time by sending a letter to the health-care provider I listed in Section II. Only one signature may appear on a line. 4. If this form is for a child under age 18 one parent or legal guardian must sign for the child. SECTION I Permission is given for the health-care provider listed in Section II to share the medical information listed in Section III about with the MassHealth DES. Please print name of applicant or member. After you have filled out the supplement submit it to your MassHealth Enrollment Center. The supplement will be sent to DES for review. DES will ask for your medical and treatment records from the providers you have listed. If you have any of your medical records please send a copy with this form. If more information or tests are needed a member of DES will get in touch with you. Disability standards require that the disability has lasted or is expected to last at least 12 months. Medical and mental health providers may include doctors psychologists therapists social workers physical therapists chiropractors hospitals health centers and clinics from whom you receive or have received treatment and yourself your work history for the past 15 years your educational background and your daily activities. Completing the Disability Supplement will give us this information and will help us make a quick decision* Please read the following instructions before beginning. Print type or write clearly and complete the supplement to the best of your ability. Sign and date a Medical Release Form for each medical and mental health provider you list on the supplement. After you have filled out the supplement submit it to your MassHealth Enrollment Center. The supplement will be sent to DES for review.

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