Massachusetts Organ Transplant Fund Application Form - The Commonwealth Of Massachusetts
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1
2The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
250 Washington Street, Boston, MA 02108-4619
Tel: 617-624-6000
Fax: 617-624-5206
Massachusetts Organ Transplant Fund
Application Form
Date of Application*:
Name of Applicant:
Date of Birth:
Address:
Phone Number:
Email:
Mailing Address (if different from above):
Name of Transplant Center:
Date of Transplant:
Type of Transplant:
Name of Health Insurance (attach copy of Schedule HC from most recent Massachusetts income tax return):
Adjusted Gross Family Income (attach copy of most recent Massachusetts income tax return):
I, ______________________, attest that the information above is accurate to the best of my knowledge.
___________________________
_________________________________
Signature of Applicant
Date
Signature of Witness
Date
*Application must be submitted annually to determine continued medical and financial eligibility
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Parent category: Financial