EOHHS-MassHealth

Name of appellant(Required)

First Last

Appeal number(Required)

Date of fair hearing(Required)

Member identification number (if available)

Name of fair hearing officer

First Last

Appellant contact information*

Telephone number(Required)

Email address(Required)

Mailing address(Required)

Street Address Address Line 2 City State ZIP Code

Attestations - You must attest to all three conditions below.(Required)

Select exactly 3 choices.

By checking this box, I attest that YES - I am the Appellant or their duly authorized representative.

By checking this box, I attest that YES - there are 14 days or fewer remaining before the due date for a decision on my MassHealth eligibility appeal.

By check this box, I attest that YES - I understand that a decision on my eligibility appeal will be issued to me within the ninety (90) day deadline from the date of the hearing.

1 This new procedure does not change your rights to appeal any MassHealth eligibility decision from the Board of Hearings under G.L. c. 30A to the Massachusetts Superior Court within thirty (30) days after you have received the decision.