Health Coverage Mail/fax Cover Sheet Template (Page 2 of 2) in pdf

Health Coverage Mail/fax Cover Sheet Template Page 2

Health Coverage Mail/Fax Cover Sheet

Applicant/Member Information

Please print clearly. Use this cover sheet plus the first page containing the barcode when

mailing or faxing documents to the Health Connector or MassHealth.

Head of Household Information

Sender

Name

: _____________________________________

: ______________________________________

Soc. Sec. No:

Phone No:

______________________________

___________________________________

Date of Birth:

______________________________

Name of Facility (if applicable):

MassHealth ID No. (if applicable):

_____________________________________________

____________________________________________

Reference ID No. (if applicable):

___________________________________________

Applicant/Member:

____________________________________________

Number of pages (including both cover sheets): _______________

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 which 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.

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Health Coverage Mail/fax Cover Sheet Template Page 2