Permission To Share Information (Psi) Form - Masshealth printable pdf download

Where to send this form

MASSHEALTH

Signature/Legal guardian

SECTION 7

Please follow the instructions below.

Permission to Share

Fill out the following section if this form is being filled

 If you are applying for health benefits and wish

Information (PSI) Form

out by someone who has the legal authority to act on

to submit a PSI, send it to

behalf of the applicant or member (such as the parent

MassHealth Enrollment Center

of a minor child, an eligibility representative, or a

Central Processing Unit

legal guardian).

 Use this form if you want MassHealth to

P.O. Box 290794

share the information we have about you with

Charlestown, MA 02129-0214

another person or organization, such as

Printed name of person filling out this form

 If you are already getting health benefits and

• a family member, friend, or other relative;

wish to submit a PSI, send it to

• someone who helps take care of you;

• someone who helps you fill out MassHealth

Signature of person filling out this form

MassHealth Enrollment Center

forms; or

P.O. Box 1231

Taunton, MA 02780

• a social worker, lawyer, or health-care

Date

advocacy group.

 If you are authorizing only specific information

 Do not use this form if you want

to be shared (such as your claims information or

Address

application file), and have checked off the second,

• information about yourself;

third, or fourth box in Section 2, send the PSI to

• information about your children under age

18 (You can usually get this without filling

Privacy Office

Telephone number

out any forms.); or

600 Washington Street

Boston, MA 02111

• your eligibility and payment information

Authority of person filling out this form to act on

to be shared with your health-care

behalf of the applicant or member:*

provider. (Your health-care provider can

get information about your MassHealth

eligibility and payment for services provided

* If this form is being filled out by someone who has been

to you without you filling out any forms.)

appointed by a court as a legal guardian or conservator,

or who has power of attorney or health-care proxy, a

 Important: If you decide that you do need to

copy of the applicable legal document must be attached.

fill out this form, you must fill out all sections

completely. Please print clearly.

PSI (Rev. 02/13)

Permission To Share Information (Psi) Form - Masshealth

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