Form FIR-1 "Financial Information Request" - Massachusetts

What Is Form FIR-1?

This is a legal form that was released by the Massachusetts MassHealth - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2016;
  • The latest edition provided by the Massachusetts MassHealth;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form FIR-1 by clicking the link below or browse more documents and templates provided by the Massachusetts Masshealth.

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Download Form FIR-1 "Financial Information Request" - Massachusetts

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Health Insurance Processing Center
P.O. Box 4405
Taunton, MA 02780
The Commonwealth of Massachusetts
1-888-665-9993
Executive Office of Health and Human Services
TTY: 1-888-665-9997
www.mass.gov/masshealth
Fax: 1-857-323-8300
Financial Information Request
Name:
Social security number:
Address:
City/Town/Zip:
Name of financial institution:
Address:
City/Town/Zip:
You or your spouse has applied for MassHealth. You must get a copy of your bank accounts to us so we can
complete the application process. If you do not have your account records, you can get them from your bank.
Sometimes banks charge a fee to get these records. You can get them at no cost with this form.
You need to complete one form for each bank where you have accounts.
 Complete the top of this form (PLEASE PRINT your name, address, and social security number and the
name and address of the financial institution).
 In Section 1, list the account number and time period that you need the bank records for.
 In Section 2, tell the bank where you want the information sent (to you or to the MassHealth
Enrollment Center listed above).
 Sign and date the form before you give it to your bank.
 Bring or mail the form to the bank.
Pursuant to M.G.L. c. 118E, § 23A, please provide, without charge, the deposit and withdrawal records
for the accounts and time periods listed below for the above-named MassHealth (Medicaid) applicant,
member, or spouse of an applicant or member.
Section 1
Account number:
Time period:
Account number:
Time period:
Account number:
Time period:
Section 2
Within two weeks of your receipt of this request, please send that information to
the above-named applicant or member; or
the address listed above.
Signature of MassHealth Applicant/Member or Spouse
Date
MassHealth Signature
FIR-1 (Rev. 06/16)
Health Insurance Processing Center
P.O. Box 4405
Taunton, MA 02780
The Commonwealth of Massachusetts
1-888-665-9993
Executive Office of Health and Human Services
TTY: 1-888-665-9997
www.mass.gov/masshealth
Fax: 1-857-323-8300
Financial Information Request
Name:
Social security number:
Address:
City/Town/Zip:
Name of financial institution:
Address:
City/Town/Zip:
You or your spouse has applied for MassHealth. You must get a copy of your bank accounts to us so we can
complete the application process. If you do not have your account records, you can get them from your bank.
Sometimes banks charge a fee to get these records. You can get them at no cost with this form.
You need to complete one form for each bank where you have accounts.
 Complete the top of this form (PLEASE PRINT your name, address, and social security number and the
name and address of the financial institution).
 In Section 1, list the account number and time period that you need the bank records for.
 In Section 2, tell the bank where you want the information sent (to you or to the MassHealth
Enrollment Center listed above).
 Sign and date the form before you give it to your bank.
 Bring or mail the form to the bank.
Pursuant to M.G.L. c. 118E, § 23A, please provide, without charge, the deposit and withdrawal records
for the accounts and time periods listed below for the above-named MassHealth (Medicaid) applicant,
member, or spouse of an applicant or member.
Section 1
Account number:
Time period:
Account number:
Time period:
Account number:
Time period:
Section 2
Within two weeks of your receipt of this request, please send that information to
the above-named applicant or member; or
the address listed above.
Signature of MassHealth Applicant/Member or Spouse
Date
MassHealth Signature
FIR-1 (Rev. 06/16)