Forms

Forms 2016-12-10T04:23:50+00:00

Please find our commonly used forms below:

Individuals and Families Applications for Coverage and Help Paying Costs

Download Applications for Health and Dental Coverage

Massachusetts Application for Health and Dental Coverage and Help Paying Costs (PDF)

Massachusetts Application for Health and Dental Coverage and Help Paying Costs (English Large Print) (PDF)

Solicitud de cobertura de servicios de salud y dental de Massachusetts y ayuda para pagar los costos (PDF)

Massachusetts Application for Health and Dental Coverage and Help Paying Costs—Additional Persons (PDF)

Special Enrollment Period Form (English PDF)

Formulario del período de inscripción especial (Español PDF)

What is the Special Enrollment Period Form? The Special Enrollment Period form should be completed after the open enrollment period ends and one of the life events listed on the form happened. You will need to fax or mail this form along with your completed paper application. If one of the life events on the Special Enrollment form did not happen, you do not need to fill out the form.

 

Important: Use this two-page cover sheet when submitting your application:
Health Coverage Mail/Fax Cover Sheet  pdf format of Health Coverage Mail/Fax Cover Sheet doc format of Health Coverage Mail/Fax Cover Sheet

 

You can also find these forms plus additional applications and member information on the MassHealth website →

 

Individuals and Families Applications for Coverage Without Help Paying Costs

Download Applications for Health and Dental Coverage

Download Application for Health and Dental Insurance Coverage Without Help Paying Costs

Descargar la Solicitud de Salud y Dental de Cobertura de Seguro Sin Ayuda en Pagar Costos

 

 

Small Businesses

Download Applications for Business Express

The Massachusetts Health Connector’s Business Express program is a fast and easy way for employers with 50 or fewer employees to offer health and dental benefits to full-time employees. There are no membership or monthly fees, and you can choose plans from the state’s leading insurers.

Download applications below to apply for Business Express:

Business Express Employer Application (PDF)

Business Express Employee Application (PDF)

Business Express New Business Checklist (PDF) 

Business Express Terms and Conditions (PDF) 

 

The application should only take 5 to 10 minutes to complete. Please note that each of your eligible employees will also need to complete an Employee Application, which you must submit to the Health Connector.