Masshealth Template

The MassHealth Adult Disability Supplement is a critical document for individuals applying for health coverage based on a disability in Massachusetts. This form collects essential information about your medical history, treatment providers, and daily activities, which is necessary for determining your eligibility. Completing this supplement accurately will help ensure a timely decision regarding your MassHealth application.

To get started, please fill out the form by clicking the button below.

Table of Contents

When applying for MassHealth, individuals with disabilities must complete the MassHealth Adult Disability Supplement, a critical document that provides essential information for determining eligibility. This form requires applicants to detail their medical and mental health history, including the names of healthcare providers who have treated them. It is vital to include comprehensive information about one’s work history, educational background, and daily activities over the past 15 years. The form emphasizes the importance of clarity and completeness, as any missing information could delay the decision-making process. To facilitate a thorough review, applicants must also sign and submit Medical Release Forms for each provider listed. After completing the supplement, it should be sent to the UMass Disability Evaluation Services, which will then request medical records from the listed providers. The urgency of filling out every section cannot be overstated, as this is not merely an application for medical benefits; it is a key step in establishing eligibility for support based on disability. For those who need assistance or have questions, resources are available, including a dedicated help line. Completing this supplement accurately and promptly is essential for a swift evaluation of eligibility.

Masshealth Sample

MassHealth

Adult Disability Supplement

Commonwealth of Massachusetts | Executive Office of Health and Human Services

Instructions for Completing the Supplement

You have indicated on your MassHealth application that you have a disability. Disability standards require that the disability has lasted or is expected to last at least 12 months. UMass Disability Evaluation Services (DES) will review your disability application for MassHealth. It is very important that you complete this Disability Supplement.

To get MassHealth based on your disability, you need to tell us about

•your medical and mental health providers. These may include doctors, psychologists, therapists, social workers, physical therapists, chiropractors, hospitals, health centers, and clinics from whom you receive or have received treatment; and

•yourself: your work history for the past 15 years, your educational background, and your daily activities.

Completing the Disability Supplement will give us this information and will help us make a quick decision.

Please read the following instructions before beginning.

•Print, or write clearly and complete the supplement to the best of your ability.

•Sign and date a Medical Release Form for each medical and mental health provider you list on the supplement.

•After you have filled out the supplement, submit it to

Disability Evaluation Services / UMASS Medical DES

P.O. Box 2796

Worcester, MA 01613-2796

DES will ask for your medical and treatment records from the providers you have listed. If you have any of your medical records, please send a copy with this form. If more information or tests are needed, a member of DES will get in touch with you. Your eligibility will be determined more quickly if all items on the supplement are filled in.

This is not an application for medical benefits. If you have not already completed a MassHealth application, you must fill one out in addition to this form. If you have any questions about how to apply, please call 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

If you need help with this form, you can call the UMass Disability Evaluation Services (DES) Help Line at 1-888-497-9890.

Fill in every section of this form. If you do not ﬁll in every section, we may not be able to decide if you are disabled.

Information about you

MALE

FEMALE

Last name First name Middle initial

Social security number

Street address

City

Apt. #

State	Zip code		Date of birth (mm/dd/yyyy)
		—

Home phone

Cell phone

Work/other phone

We may need to schedule a doctor’s appointment for you. What are the best times for you to go to an appointment? Please check all the times that are good for you.

Any time is ok	Monday a.m.	Tuesday a.m.		Wednesday a.m.
	Monday p.m.	Tuesday p.m.		Wednesday p.m.
Did you apply for Social Security or SSI/SSDI benefits?			yes	no
If yes, did you see a doctor for an exam?
Doctor’s name

Thursday a.m.	Friday a.m.
Thursday p.m.	Friday p.m.

Date of exam _____/_____/________

MADS-A/MR COMBO (Rev. 04/15)

Please go to the next page.

PART 1 Your health problems

List and describe all your medical and mental health problems. If you are getting treatment for the problem, please tell us what kind of treatment.

List your medical and/or	Describe the symptoms or pain related to each health	Date when	Medications/
mental health problems.	problem.	problem started.	treatment

Depression	Very tired all the time. Hard to get out of bed in the morning.	April 2010	None
	I cry a lot during the day. I can’t control when I cry.

Back pain	Pain starts in my lower back and goes down my leg	June 2007	Skelexin

Did any of your health problems start because of an accident or injury? If yes, please explain.

yes

PART 2 Information about all your medical and mental health providers

Did you get any health care in the past year?

yes

If yes, please list every medical and mental health provider that treated you for any of your health problems since they started. A medical or mental health provider may include a doctor, psychologist, therapist, social worker, physical therapist, chiropractor, hospital, health center, and clinic from which you receive treatment. You can write on a separate piece of paper if you run out of space.

If you are receiving treatment from only one facility, list only that facility.

Name of medical and mental health providers	Reason for visit	Was this visit
		in the past year?

		yes	no

		yes	no

		yes	no

		yes	no

Please fill out a Medical Records Release Form for each medical and mental health provider on this list. Be sure to sign and date each form. These release forms are at the end of this packet. If you need more copies of the Medical Release Form, call a MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled) or download the form at www.mass.gov/masshealth.

PART 3 Where you live

Where do you live? (Check one.)

House or apartment

Group home

Other (describe)

State facility

Nursing home

Rehabilitation hospital

Homeless

MADS-A/MR COMBO (Rev. 04/15)

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PART 4 What you can do

Are you	right handed?	left handed?
Do your medical or mental health problems make it hard for you to do any of the following things?

		If yes,	If yes, please explain below.
		check here

Dress and bathe			My shoulder pain makes it hard for me to lift my arm over my head. This
Dress and bathe			makes it hard to put on shirts or wash my hair.
			makes it hard to put on shirts or wash my hair.

Do regular housework			When I am depressed, I don’t care if my house is clean.

Sit

Stand

Walk

Bend

Reach

Lift

Remember

See

Hear

Use your hands

Dress and bathe

Do regular housework

Listen to music

Watch TV

Use a computer

Read

Talk on the phone

Go outside

Go for a walk

Go shopping

Go to the doctor

Visit friends and family

Go to school

Handle money/use an ATM

Drive a car

Take a bus, train, or taxi

Play sports

Other (describe)

MADS-A/MR COMBO (Rev. 04/15)

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PART 5	Your language

Do you speak English?		yes	no	limited
Do you understand English?			yes	no	limited
Do you read English?		yes	no	limited
Do you write English?		yes	no	limited
What is your first language?
Can you read in your first language?				yes	no	limited
Can you write in your first language?				yes	no	limited

PART 6

School

Check the highest grade of school you finished.

Associate’s degree

GED

Bachelor’s degree

What year did you finish this

grade?

Where did you go to school?

Did you repeat any grades?

yes

Were you in special education?

yes

not sure

Did you finish more than 12 years of school?

yes

If yes, please list your degree and major

Did you get any other training?

yes

If yes, please fill out the

sections below.

Type of training

Year

Finished

Certified/Licensed

Building trades

yes

Electronics

yes

Cooking

yes

Auto mechanics

yes

Computers

yes

Hairdressing

yes

Cosmetology

yes

Nurse’s aide

yes

Secretarial

yes

Other (describe)

yes

PART 7

Your work

Do you work now?

yes

If no, when did you stop working? Date ___ /___ /______

Did any of your medical or mental health conditions cause problems at work? If yes, plesae explain.

yes

MADS-A/MR COMBO (Rev. 04/15)

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Part 7. Your work (continued)

List all your jobs from the last 15 years. Do the best that you can. If you do not know the exact dates, write your best guess.

Start with the job you have now or your last job. Add a piece of paper if you need more space. You can attach a resume if you have one. Here is a sample.

Job title Packer

Dates worked: From (Month/Year) March 2012

To (Month/Year) May 2012

Job duties (List everything you did.) Put three golf balls into a small box. Packed 24 small boxes into a case. Sealed the case with packing tape. Loaded cases onto a platform.

How many hours did you work each week? 40			How much did you make an hour? $9.00/hour

Reason for leaving Moved

Job title		Dates worked: From (Month/Year)			To (Month/Year)

Job duties (List everything you did.)

How many hours did you work each week?			How much did you make an hour?

Reason for leaving

Job title		Dates worked: From (Month/Year)			To (Month/Year)

Job duties (List everything you did.)

How many hours did you work each week?			How much did you make an hour?

Reason for leaving

Job title		Dates worked: From (Month/Year)			To (Month/Year):

Job duties (List everything you did.)

How many hours did you work each week?			How much did you make an hour?

Reason for leaving

Check each of the things you do in your job. If you do not work, check each thing you did in your last job.
Doing paperwork	Using a computer	Assembling		Operating machines	Filing
Serving people	Counting & packing	Construction		Using phone	Driving a car or truck
Moving things	Cleaning	Using office machines		Using cash register	Driving a forklift
Using power tools	Using hand tools	Other (please describe)

Circle the number of hours you do each thing in your job. If you do not work, circle the number of hours you did each thing in your last job.

Activity	Hours in a Day

Walk or stand	0	1	2	3	4	5	6	7	8
Sit	0	1	2	3	4	5	6	7	8
Reach	0	1	2	3	4	5	6	7	8

Check the weight you lift or carry most.
Less than 10 lbs.	10 lbs.	20 lbs.	25 lbs.	50 lbs.	100 lbs.	More than 100 lbs.
Check the heaviest weight you lift.
Less than 10 lbs.	10 lbs.	20 lbs.	25 lbs.	50 lbs.	100 lbs.	More than 100 lbs.

MADS-A/MR COMBO (Rev. 04/15)

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PART 8 Your comments

Use this space to write any additional information about why you cannot work.

PART 9 Your signature and rights

THIS SECTION MUST BE COMPLETED.

You have the right to privacy. The information on this form is confidential. All possible precautions will be taken to ensure your privacy rights.

Signature of Applicant/Guardian/Authorized Representative

Date _____/_____/________

Authorized Representative

If this form is being filled out by someone with the legal authority to act on behalf of the applicant/member (such as the parent of an adult disabled child or spouse, an authorized representative, or a legal guardian), give us the following information.

Signature of person filling out this form

Print name

Authority of person filling out this form on behalf of the applicant/member

DES may send copies of notices to the authorized representative. This area does not authorize release of medical records.

You may choose an authorized representative to help you with some or all of the responsibilities of applying for or getting health benefits.

You can do this by filling out a MassHealth Authorized Representative Designation Form (ARD). To ask for an ARD form, call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

HELP WITH THIS FORM

Did you need help to fill out this form? If yes, why did you need help?

yes

REMINDER

Did you remember to

complete a medical release form for each medical or mental health provider listed on page 2? sign all medical release forms?

sign this Disability Supplement above?

include a completed and signed Authorized Representative Designation Form (ARD) if needed?

MADS-A/MR COMBO (Rev. 04/15)

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MassHealth

Medical Records Release Form

Commonwealth of Massachusetts | Executive Office of Health and Human Services | www.mass.gov/masshealth

MassHealth Disability Evaluation Service

This MassHealth Medical Records Release Form helps us get medical information from your health-care provider so that the MassHealth Disability Evaluation Service (DES) can make a disability determination.

Please read the instructions carefully before you fill out this form. If you leave any sections of this form blank, this permission will not be valid, and the health-care provider will not be able to share your information with the MassHealth DES. If the health-care provider does not share medical information with the MassHealth DES, we will not be able to make a disability determination.

General instructions for ﬁlling out the Medical Records Release Form

You must follow these instructions when filling out the medical records to the MassHealth DES if you do not fill disability determination.

Medical Records Release Forms. The health-care providers will not send out the forms the right way. We need copies of medical records to make a

1.Sign and date a Medical Records Release Form for each doctor, hospital, health center, clinic, or other health-care provider you listed in the Disability Supplement.

2.All signatures must be in ink and must be originals. No copies or stamps of signatures are permitted.

3.Only one signature may appear on a line.

4.If this form is for a child younger than age 18, one parent or legal guardian must sign for the child.

SECTION I

Permission is given for the health-care provider listed in Section II to share the medical information listed in Section III about

with the MassHealth DES.

(Please print name of applicant or member.)

SECTION II

Please print the name of the health-care provider that may share medical information with the MassHealth DES.

Name of doctor, health center, or other health-care provider

Street address

City, state, zip

Phone ( )

SECTION III

The health-care provider listed in Section II above may share the following information with the MassHealth DES to determine eligibility for MassHealth benefits.

All medical records or other information about my treatment, hospitalization, or outpatient care for conditions including

psychological/psychiatric impairments		how impairments affect activities of daily living and ability to work
AIDS/HIV		drug and alcohol use
other (please describe)

Check here if you do not want the health-care provider to share information about AIDS/HIV status.

Check here if you do not want the health-care provider to share information about drug or alcohol use.

MADS-MR (Rev. 04/15)

(continued on back)

SECTION IV

Any medical information that the health-care provider releases to the MassHealth Disability Evaluation Service (DES) will continue to be protected by federal privacy laws.

This permission to release medical information to the MassHealth DES ends six months from the date you sign this release form, unless you have cancelled permission in writing before then.

I understand that I may cancel this permission at any time by sending a letter to the health-care provider I listed in Section II.

I understand that even if I cancel this permission, the health-care provider I listed in Section II cannot take back any information that it shared with the MassHealth DES when it had my permission to do so.

I also understand that my decision whether to give the health-care provider permission to share medical information with the MassHealth DES is voluntary. However, I also understand that if I do not give permission to the health-care provider to share medical information with the MassHealth DES, the MassHealth DES will not be able to make a disability determination, and the decision about eligibility for MassHealth benefits will be made without consideration of any disability claimed.

SECTION V

Signature of applicant/member			Date

Print name of applicant/member		Phone (	)

Street address		Date of birth

City/Town	State	Zip code	—

If this form is being filled out by someone who has the legal authority to act on behalf of the applicant/member

(such as the parent of a minor child, an eligibility representative, or a legal guardian), please give us the following information.

Signature of person filling	out this form

Print name	Date

Authority of person filling	out this form to act on behalf of the applicant/member

Please give us a copy of the document that gives this person the authority to act on behalf of the applicant/member.

MassHealth will send you back a copy of this signed Medical Records Release Form for you to keep for your records. You can also ask for another copy of this signed Medical Records Release Form at any time by contacting MassHealth at the following address.

Disability Evaluation Services

UMASS Medical DES

P.O. Box 2796

Worcester, MA 01613-2796

MassHealth

Medical Records Release Form

Commonwealth of Massachusetts | Executive Office of Health and Human Services | www.mass.gov/masshealth

MassHealth Disability Evaluation Service

General instructions for ﬁlling out the Medical Records Release Form

You must follow these instructions when filling out the medical records to the MassHealth DES if you do not fill disability determination.

Medical Records Release Forms. The health-care providers will not send out the forms the right way. We need copies of medical records to make a

1.Sign and date a Medical Records Release Form for each doctor, hospital, health center, clinic, or other health-care provider you listed in the Disability Supplement.

2.All signatures must be in ink and must be originals. No copies or stamps of signatures are permitted.

3.Only one signature may appear on a line.

4.If this form is for a child younger than age 18, one parent or legal guardian must sign for the child.

SECTION I

Permission is given for the health-care provider listed in Section II to share the medical information listed in Section III about

with the MassHealth DES.

(Please print name of applicant or member.)

SECTION II

Please print the name of the health-care provider that may share medical information with the MassHealth DES.

Name of doctor, health center, or other health-care provider

Street address

City, state, zip

Phone ( )

SECTION III

The health-care provider listed in Section II above may share the following information with the MassHealth DES to determine eligibility for MassHealth benefits.

All medical records or other information about my treatment, hospitalization, or outpatient care for conditions including

psychological/psychiatric impairments		how impairments affect activities of daily living and ability to work
AIDS/HIV		drug and alcohol use
other (please describe)

Check here if you do not want the health-care provider to share information about AIDS/HIV status.

Check here if you do not want the health-care provider to share information about drug or alcohol use.

MADS-MR (Rev. 04/15)

(continued on back)

SECTION IV

Any medical information that the health-care provider releases to the MassHealth Disability Evaluation Service (DES) will continue to be protected by federal privacy laws.

This permission to release medical information to the MassHealth DES ends six months from the date you sign this release form, unless you have cancelled permission in writing before then.

I understand that I may cancel this permission at any time by sending a letter to the health-care provider I listed in Section II.

SECTION V

Signature of applicant/member			Date

Print name of applicant/member		Phone (	)

Street address		Date of birth

City/Town	State	Zip code	—

If this form is being filled out by someone who has the legal authority to act on behalf of the applicant/member

(such as the parent of a minor child, an eligibility representative, or a legal guardian), please give us the following information.

Signature of person filling	out this form

Print name	Date

Authority of person filling	out this form to act on behalf of the applicant/member

Please give us a copy of the document that gives this person the authority to act on behalf of the applicant/member.

Disability Evaluation Services

UMASS Medical DES

P.O. Box 2796

Worcester, MA 01613-2796

▼ Masshealth PDF Form

Document Attributes

Fact Name	Description
Purpose	The MassHealth Adult Disability Supplement is designed to collect information about an applicant's disability, medical history, and treatment to determine eligibility for MassHealth benefits.
Eligibility Criteria	To qualify for MassHealth based on a disability, the condition must have lasted or be expected to last for at least 12 months.
Submission Instructions	Applicants must complete the supplement, sign a Medical Release Form for each medical provider listed, and submit it to the UMass Disability Evaluation Services.
Contact Information	For assistance, applicants can call the UMass Disability Evaluation Services Help Line at 1-888-497-9890 or the MassHealth Enrollment Center at 1-888-665-9993.
Additional Applications	This supplement is not an application for medical benefits. Applicants must also complete a separate MassHealth application.
Governing Laws	The MassHealth program operates under Massachusetts General Laws Chapter 118E, which outlines the state's health care financing and eligibility requirements.

Masshealth: Usage Instruction

Completing the MassHealth Adult Disability Supplement is an important step in your application process. This form gathers necessary information about your health, work history, and daily activities to help determine your eligibility. Make sure to fill it out carefully and provide as much detail as possible.

Begin by printing or writing clearly in each section of the form.
Fill in your personal information, including your last name, first name, middle initial, social security number, address, phone numbers, and date of birth.
Indicate your gender by checking the appropriate box.
Provide details about your health problems in Part 1. List all medical and mental health issues, describe symptoms, and note when they started.
In Part 2, list all medical and mental health providers you have seen in the past year. Include their names, the reason for your visit, and whether the visit occurred in the past year.
Complete Part 3 by checking where you currently live, such as a house, apartment, or other options.
In Part 4, indicate if your health problems affect your ability to perform daily activities. Check the relevant boxes and provide explanations as needed.
Part 5 asks about your language skills. Answer questions about your ability to speak, understand, read, and write English.
For Part 6, check the highest grade of school you completed and provide details about any degrees or training you received.
In Part 7, answer whether you are currently working. If not, provide the date you stopped working and describe any work-related issues caused by your health conditions.
List all jobs from the past 15 years, including job titles, dates worked, duties, hours worked per week, and hourly pay. You can attach additional pages if needed.
Finally, review the form to ensure every section is completed. Sign and date the Medical Release Forms for each provider listed.
Submit the completed form and any medical records to the address provided: Disability Evaluation Services / UMASS Medical DES, P.O. Box 2796, Worcester, MA 01613-2796.

Once submitted, the Disability Evaluation Services will review your information and may contact you for further details or to schedule an appointment. Make sure to keep a copy of your completed form for your records.

Frequently Asked Questions

What is the purpose of the MassHealth Adult Disability Supplement?

The MassHealth Adult Disability Supplement is a form designed to gather essential information regarding an individual's disability for the purpose of determining eligibility for MassHealth benefits. It requires applicants to provide details about their medical and mental health providers, their work history, educational background, and daily activities. This information is crucial for the UMass Disability Evaluation Services to assess the applicant's condition accurately.
How should I complete the Disability Supplement?

It is important to fill out the Disability Supplement clearly and completely. Applicants should print or write legibly, ensuring that all sections are filled out to the best of their ability. Additionally, a Medical Release Form must be signed and dated for each medical and mental health provider listed. If any section is left incomplete, it may delay the decision regarding eligibility.
What should I do if I have questions while filling out the form?

If you encounter any questions or need assistance while completing the Disability Supplement, you can reach out to the UMass Disability Evaluation Services Help Line at 1-888-497-9890. For general inquiries about the application process, you may also contact the MassHealth customer service at 1-800-841-2900. They can provide guidance and support to ensure your application is completed accurately.
What happens after I submit the Disability Supplement?

Once the Disability Supplement is submitted to the UMass Disability Evaluation Services, they will review the information provided and may request medical and treatment records from the listed providers. If additional information or tests are required, a representative from DES will contact the applicant. Completing the form thoroughly can expedite the eligibility determination process.
Is the Disability Supplement the same as a MassHealth application?

No, the Disability Supplement is not an application for medical benefits. If you have not already completed a MassHealth application, it is necessary to do so in addition to submitting the Disability Supplement. The two forms serve different purposes, and both must be completed to ensure a comprehensive review of your eligibility for MassHealth benefits.

Common mistakes

Filling out the MassHealth form can be a daunting task, and mistakes can lead to delays in receiving assistance. One common mistake is failing to provide complete information. Every section of the form is important. If you skip a section or leave it blank, it may hinder the decision-making process regarding your eligibility.

Another frequent error is not signing and dating the Medical Release Forms. Each provider listed on the supplement requires a signed release form. Without these signatures, the Disability Evaluation Services cannot access your medical records, which can slow down your application.

Many individuals also forget to include all relevant medical and mental health providers. It is crucial to list every provider you have seen for your health problems. Omitting even one provider can lead to incomplete information, which may affect your eligibility.

Inaccurate details about your medical conditions can create further complications. When describing your health problems, be as specific as possible. Vague descriptions may not adequately convey the severity of your situation, which is essential for a proper assessment.

People sometimes overlook the importance of providing their work history. The form asks for a detailed account of your employment over the past 15 years. If you do not provide this information, it may raise questions about your current capabilities and limitations.

Failing to include your educational background is another mistake. The form requests information about your schooling and any training you have received. This information helps assess your skills and potential for work, so be sure to include it accurately.

Some applicants may neglect to check their availability for appointments. The form asks for your preferred times for doctor visits. If you do not indicate your availability, it may complicate scheduling and delay your treatment.

Lastly, not seeking help when needed can lead to mistakes. If you find the form confusing, do not hesitate to reach out for assistance. You can call the UMass Disability Evaluation Services Help Line for guidance. Taking this step can help ensure that your application is completed correctly and submitted promptly.

Documents used along the form

When applying for MassHealth based on a disability, there are several important documents that may accompany your application. Each of these forms serves a specific purpose and provides essential information to help determine your eligibility. Below is a list of commonly used documents that can support your MassHealth application.

MassHealth Application Form: This is the primary document that initiates your request for MassHealth benefits. It collects basic information about you, your household, and your financial situation. Completing this form is crucial before submitting any supplementary documents.
Medical Records Release Form: This form allows your healthcare providers to share your medical records with MassHealth. It is necessary for each provider listed in your Disability Supplement. Without this authorization, your application may face delays.
Social Security Administration (SSA) Benefit Application: If you have applied for Social Security or SSI/SSDI benefits, including a copy of your SSA application can provide additional context regarding your disability status. This document supports your claim and may expedite the review process.
Proof of Income and Assets: Documents such as pay stubs, bank statements, and tax returns help verify your financial situation. MassHealth uses this information to assess your eligibility for coverage based on income guidelines.

Gathering these documents will not only streamline your application process but also ensure that you provide a comprehensive view of your circumstances. By preparing these forms, you can help facilitate a quicker decision regarding your MassHealth eligibility.

Similar forms

The MassHealth Adult Disability Supplement shares similarities with several other important documents that individuals may encounter when applying for disability-related services or benefits. Below is a list of nine documents that are comparable to the MassHealth form, along with explanations of how they are alike.

Social Security Disability Insurance (SSDI) Application: Like the MassHealth form, the SSDI application requires detailed personal information about the applicant's medical history, treatment providers, and the impact of their disability on daily activities.
Supplemental Security Income (SSI) Application: This document, similar to the MassHealth form, assesses an individual's financial status and disability. Both forms aim to gather comprehensive information to evaluate eligibility for assistance.
Medicaid Application: The Medicaid application process mirrors the MassHealth form in that it collects information about medical conditions, treatment history, and personal circumstances to determine eligibility for health coverage.
Disability Determination Services (DDS) Form: This form is used to evaluate disability claims and requires similar medical and personal information as the MassHealth form, focusing on the applicant's ability to work and function in daily life.
Veterans Affairs Disability Claim Form: Veterans seeking disability benefits must complete this form, which, like the MassHealth form, gathers information about medical conditions, treatment history, and how these affect the veteran's life.
Long-Term Disability Insurance Claim Form: This document requires detailed information about the claimant's health issues and their impact on work capacity, paralleling the information requested in the MassHealth supplement.
Workers' Compensation Claim Form: Individuals filing for workers' compensation must provide details about their injury or illness, medical treatments, and work history, akin to the requirements of the MassHealth form.
Functional Capacity Evaluation (FCE): An FCE assesses an individual's ability to perform work-related tasks, much like the MassHealth form evaluates daily living activities and work history in relation to disability.
State Disability Insurance (SDI) Application: This application, similar to the MassHealth supplement, requires comprehensive information about the applicant’s medical conditions and how they affect their ability to work.

Dos and Don'ts

When filling out the MassHealth form, there are important dos and don'ts to keep in mind. Here’s a helpful list to guide you:

Do print or write clearly to ensure your information is legible.
Do complete every section of the form. Missing information can delay your application.
Do sign and date a Medical Release Form for each provider you list.
Do submit the form to the correct address: Disability Evaluation Services, UMASS Medical, P.O. Box 2796, Worcester, MA 01613-2796.
Do include any relevant medical records you have with your submission.
Don't leave any sections blank. This could hinder your eligibility determination.
Don't forget to call the help line if you have questions: 1-888-497-9890.
Don't submit this form without completing a MassHealth application if you haven't already done so.
Don't hesitate to ask for assistance if you need help with the form.

Misconceptions

Misconception 1: The MassHealth form is just a simple application.

Many believe that the MassHealth form is straightforward. In reality, it requires detailed information about your medical history, mental health providers, and personal circumstances. Completing it thoroughly is essential for a timely decision.

Misconception 2: You don’t need to provide medical records.

Some applicants think that medical records are optional. However, submitting relevant medical records can significantly speed up the review process and strengthen your application.

Misconception 3: You can submit the form without a Medical Release Form.

It’s a common misunderstanding that the Disability Supplement can be submitted alone. Each medical provider listed requires a signed Medical Release Form for your application to be complete.

Misconception 4: The Disability Supplement is the only form needed.

Many applicants mistakenly believe that the Disability Supplement is sufficient. It’s important to remember that a separate MassHealth application is also necessary for eligibility.

Misconception 5: You can leave sections blank if you don’t have all the information.

Some think it’s acceptable to skip questions. However, incomplete forms may lead to delays or even denials, as every section is crucial for assessing your disability status.

Misconception 6: You don’t need to explain your daily activities.

Applicants often overlook the importance of detailing daily activities. This information helps assess how your disability impacts your life and is vital for a complete evaluation.

Misconception 7: You can submit the form without checking for accuracy.

Some individuals believe that minor errors won’t matter. However, inaccuracies can lead to misunderstandings or delays in processing your application, so it’s essential to double-check all information.

Misconception 8: Assistance is not available for filling out the form.

Many people think they must complete the form independently. In fact, help is readily available through the UMass Disability Evaluation Services Help Line for anyone needing guidance.

Key takeaways

Complete the MassHealth Adult Disability Supplement thoroughly. Provide as much detail as possible about your medical and mental health history.
List all your medical and mental health providers. This includes doctors, therapists, and hospitals. Ensure you include the reason for each visit and if it occurred in the past year.
Sign and date a Medical Release Form for each provider listed. This allows MassHealth to access your medical records.
Submit the completed form to the UMass Disability Evaluation Services at the specified address. Consider including any medical records you have on hand.
Be aware that this form is not an application for medical benefits. You must complete a separate MassHealth application if you haven’t already.
Fill out every section of the form. Incomplete sections may delay your eligibility determination.
If you have questions or need assistance, contact the UMass Disability Evaluation Services Help Line or the MassHealth Enrollment Center.