Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 27
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34SUPPlEMENt
Accommodation
C
If you answered yes to Question 14 in Step 2 about yourself or any household member needing reasonable accommodation
because of a disability or injury, check all that apply below, and list name(s).
1. Condition
Blind—Name(s):
Deaf—Name(s):
Developmentally disabled—Name(s):
Hard of hearing—Name(s):
Intellectually disabled—Name(s):
Low vision—Name(s):
Physically disabled—Name(s):
Other (Please explain.)—Name(s):
2. Accommodation
American Sign Language (ASL) interpreter—Name(s):
Assistive listening device—Name(s):
Communication Access Real-time Translations (CART)—Name(s):
Large print publications—Name(s):
Publications in braille—Name(s):
Publications in electronic format—Name(s):
Text telephone (TTY)—Name(s):
Video Relay Service (VRS)—Name(s):
Other (Please explain.)—Name(s):
Page 25
SUPPlEMENt C Accommodation
ACA-3 (Rev. 10/16)
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