Personal-Care-Attendant Supplement English - Mass - mass 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Applicant/Member information section. Clearly print your last name, first name, middle initial, social security number, date of birth, address, city, state, zip code, and telephone number.
3. In the health problems section, list all medical and mental health issues that affect your daily living activities. Be thorough; if you need more space, attach a separate sheet with your name and social security number.
4. Next, complete the daily living activities chart. Indicate whether you need hands-on help for each activity listed (mobility, medication management, bathing/grooming, dressing/undressing, exercises, eating, toileting) and specify how often you require assistance.
5. Provide caregiver information by listing names and relationships of those who assist you. This helps clarify your support system.
6. Finally, sign and date the form to certify that all information is accurate. If applicable, include an Authorized Representative Designation Form.

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