Health Coverage Mail/fax Cover Sheet Template


Health Coverage
Mail/Fax Cover Sheet
Last four digits of Head of Household’s Social Security Number: ___ ___ ___ ___ OR
Head of Household initials: __ __ and DOB (MM/DD/YYYY): ____/____/________
Do NOT photocopy the cover sheet containing the barcode. For barcodes to work, the sheet with the barcode
must be an original, not a copy. Use a separate two-page cover sheet for each household. Do NOT use the
same two-page cover sheet to send items for more than one household.
Always mail or fax verifications to the address or fax on the letter requesting the verifications. If you are not sure
where to fax or mail documents, contact the MassHealth Customer Service Center at 1-800-841-2900.
Fax or Mail
Type of Document 
Where to Send 
for Health
» New paper applications for subsidized
Subsidized applications and verifications for
(assistance with paying) health coverage,
eligibility should be sent to:
including Health Connector (ConnectorCare
plans and those seeking premium tax
Health Insurance Processing Center
credits), MassHealth, or HSN coverage
P.O. Box 4405
» Eligibility verification documents for
Taunton, MA 02780
MassHealth and the Health Connector
Fax: 857-323-8300
» MassHealth Renewal forms
» New paper applications for unsubsidized
Unsubsidized applications and verifications for
(no assistance with paying) health insurance
IDP and Closed Enrollment should be sent to:
through the Health Connector
Massachusetts Health Connector
» Closed Enrollment verification for Health
133 Portland Street, 1st Floor
Connector plan
Boston, MA 02114-1707
Fax: 617-887-8745
» MassHealth Application for Health
These applications should be sent to:
Coverage for Seniors and People Needing
Central Processing Unit
Long-Term-Care Services (SACA-2) and
P.O. Box 290794
Supplement A + Buy-In applications
Charlestown, MA 02129
Fax: 617-887-8799
Please allow time for the Health Connector or MassHealth to receive your documents and process them.
If your benefits have ended and you need medical services, call the MEC at 1-888-665-9993
(TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled).
This facsimile transmittal may contain information that is privileged, confidential, or exempt from disclosure under applicable
law. It is intended for the use of only the individual or department to whom it is addressed. If you are not the recipient or the
employee or the agent responsible for the delivery of this transmittal to the intended recipient, please notify the sender by
telephone at the above number and destroy the attached documents. Anyone other than the intended recipient is hereby notified
that any dissemination, distribution, or copying of this communication is strictly prohibited.
HC-CS (Rev. 06/16)
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