EOHHS-MassHealth

Step 1 of 2

50%

Contact Information

Agency(Required)

Type of organization:(Required)

Community Based Organization

Community Health Center

Provider (e.g. physician office, ASAP, etc.)

Legislative office

Municipal organization (e.g. Community/Senior Center, Council on Aging, etc.)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Service Request Information

Type of request:

Education/information session

Resource table

Enrollment event

What topics would you like to cover?

MassHealth eligibility criteria

How to apply for MassHealth

Health plans and/or enrollment

Services and/or programs

Select all that apply

How will it be held?

In-person

Virtual

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Who will be the point of contact for follow-up?

Self

Other person

Name

First Last

Phone

Email

Requesting Date

Month

Day

Year

Requesting Time

Hours

:

Minutes

AM/PM

Duration

Hour(s)

Any additional agencies attending?

Yes

No

If yes, please provide names of additional agencies attending.

If more than one, put agencies on separate lines.

Who will be attending? (e.g., social workers, outreach workers)

Number of attendees

Issues that you want reviewed:

Purpose of in-service request: