EOHHS-MassHealth

Contact Information (all fields required)

Name(Required)

First Last

Phone(Required)

Email address (electronic requests will be fulfilled via secure email)(Required)

A business email address must be provided; RAs will not be sent to a personal email address.

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Provider number (PID/SL)(Required)

Note to group practices: If you bill under individual provider numbers, please use the individual provider number, not the group practice provider number.

If you have sent a Duplicate Remittance Advice Form on a previous occasion, please include your justification reason for sending an additional request. If we have received several requests from you for multiple RAs, future requests may not be fulfilled.(Required)

Remittance Advice Date(Required)