Massachusetts Organ Transplant Fund Application Form - The Commonwealth Of Massachusetts Page 2


Applicant must provide the following required attachments:
 A signed letter from the established transplant center, or current physician overseeing direct care related
to the transplant, providing diagnosis, patient status and patient’s current level of activity
 Copy of most recent Massachusetts and Federal Income Tax Returns and Schedule HC (health insurance
verification form)
Send completed application form along with required attachments to:
Lea Susan Ojamaa, Director
Division of Prevention and Wellness
250 Washington Street, 4
Boston, MA 02108


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