Disability Supplement Form

MassHealth can provide some very good services for kids and adults with disabilities!

But you have to fill out this form if you haven't already.

Make sure your family member has filed a MassHealth Disability Supplement Form.

This can help them qualify for the right MassHealth plan, and get extra benefits.

If you haven't already done this, here's what you can do:

1. Click one of the buttons below, based on your family member's age

2. Follow the step-by-step instructions to fill out the form and submit it (you can print out these instructions)

What you can do:

1. Click the button below to download a PDF of the MassHealth Disability Supplement Form (Child)

2. If you are not the parent or legal guardian, click the button below to download a PDF of the MassHealth Authorized Representative Designation Form. This will give you permission to sign other forms for your family member.

3. Read the directions carefully and give as much detail as possible. Use extra sheets of paper if you need more room to explain, and attach them to the application.

If your family member needs urgent medical or psychological services right away and you need this processed quickly, you should attach a letter to the front of the disability supplement explaining your situation. Include this sentence: "I request that DES expedite this disability supplement so that my family member can access the care they need to stay safe and healthy in the community".

What to do next:

  1. Make a copy of the completed Disability Supplement form and keep for your records

  2. Mail the form to the address below. Since this is an important form, try to mail it from the post office and ask for a return receipt (this is your proof that you mailed the form). Mail everything to: Disability Evaluation Services UMass Medical DESP.O. Box 2796 Worcester, MA 01613-2796

  3. MassHealth will send you a decision letter within 90 days of getting the form. You can call the MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997) for more information

Source: MassHealth

What you can do:

  1. Click the button below to download a PDF copy of the form

  2. Read the directions carefully

  3. Fill it out completely, and give as much detail as possible

  4. Use extra sheets paper if you need more room to answer any of the questions. Attach them to the application

  5. Fill out other forms as needed and attach them

If your family member needs urgent medical or psychological services right away and you need this processed quickly, you can attach a letter to the front of the disability supplement explaining your situation. Try including this sentence: "I request that DES expedite this disability supplement so that my family member can access the care they need to stay safe and healthy in the community".

Source: MassHealth

 

Source: MassHealth

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