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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.
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)
TypeofDocument WheretoSend
» New paper applications for subsidized
(assistance with paying) health coverage,
including Health Connector (ConnectorCare
plans and those seeking premium tax
credits), MassHealth, or HSN coverage
» Eligibility verification documents for
MassHealth and the Health Connector
» MassHealth Renewal forms
Subsidized applications and verifications for
eligibility should be sent to:
Health Insurance Processing Center
P.O. Box 4405
Taunton, MA 02780
Fax: 857-323-8300
» New paper applications for unsubsidized
(no assistance with paying) health insurance
through the Health Connector
» Closed Enrollment verification for Health
Connector plan
Unsubsidized applications and verifications for
IDP and Closed Enrollment should be sent to:
Massachusetts Health Connector
133 Portland Street, 1st Floor
Boston, MA 02114-1707
Fax: 617-887-8745
» MassHealth Application for Health
Coverage for Seniors and People Needing
Long-Term-Care Services (SACA-2) and
Supplement A + Buy-In applications
These applications should be sent to:
Central Processing Unit
P.O. Box 290794
Charlestown, MA 02129
Fax: 617-887-8799
Important
Message
Fax or Mail
Information
for Health
Connector
or
MassHealth