Masshealth request for services form 2026

1. Click ‘Get Form’ to open the masshealth request for services form in the editor.
2. Begin by filling in the member information section. Enter the last name, first name, telephone number, address, city, zip code, and indicate if they are a MassHealth member or if their application is pending.
3. In the clinical eligibility determination section, check all applicable services requested such as pre-admission nursing facility or adult day health.
4. Complete the screening for mental illness and developmental disabilities by checking all relevant diagnoses that apply to the member/applicant.
5. Provide additional information regarding caregiver availability and any significant changes in condition over the past 30 days.
6. Finally, ensure that a registered nurse completes and signs the form before submission. Attach any required documents as specified for community or nursing facility providers.

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