Form NCP-1-LP "Noncustodial Parent Form - Large Print" - Massachusetts

What Is Form NCP-1-LP?

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 April 1, 2015;
  • 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 NCP-1-LP by clicking the link below or browse more documents and templates provided by the Massachusetts Masshealth.

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Download Form NCP-1-LP "Noncustodial Parent Form - Large Print" - Massachusetts

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Commonwealth of Massachusetts
EOHHS
NONCUSTODIAL PARENT FORM
Instructions
This form is being sent to you because you
recently completed an application for certain
state health plans such as MassHealth and listed
one or more children in your household, without
listing two custodial parents. This indicates that
the child(ren) may have a noncustodial parent. A
noncustodial parent is a parent who does not live
with his or her child.
This form must be filled out and signed by the
custodial parent or legal guardian of the children
listed on the application for health care coverage.
You must provide the requested information for
each child who has a noncustodial parent.
NCP-1-LP (Rev. 04/15)
Commonwealth of Massachusetts
EOHHS
NONCUSTODIAL PARENT FORM
Instructions
This form is being sent to you because you
recently completed an application for certain
state health plans such as MassHealth and listed
one or more children in your household, without
listing two custodial parents. This indicates that
the child(ren) may have a noncustodial parent. A
noncustodial parent is a parent who does not live
with his or her child.
This form must be filled out and signed by the
custodial parent or legal guardian of the children
listed on the application for health care coverage.
You must provide the requested information for
each child who has a noncustodial parent.
NCP-1-LP (Rev. 04/15)
To get MassHealth, you agree to cooperate with
MassHealth and the Child Support Enforcement
Division of the Massachusetts Department of
Revenue (DOR) in collecting medical support from
noncustodial parents. This means that you must fill
out this form to help us identify the noncustodial
parent who has to pay for medical care for you and
your children. Cooperation also means that you
may have to, among other things,
• appear at a state or local office to provide
relevant information;
• appear as a witness at a court or other
proceeding;
• provide information under penalty of perjury,
including information about the identity,
location, and employment of a noncustodial
parent;
• pay to MassHealth any support or medical
care funds received that are covered by the
assignment of rights; and
• take any other reasonable steps to assist in
establishing paternity, securing medical support
and payments, and identifying and providing
information to help us pursue liable third parties.
2
Your eligibility could be affected if you do not fill
out this form in its entirety and do not meet the
exceptions described below.
Please fax or mail to
Health Insurance Processing Center
P.O. Box 4405
Taunton, MA 02780
Fax: 1-857-323-8300
Important
MassHealth will not deny or terminate your child’s
MassHealth benefits if you do not cooperate,
but your eligibility may be impacted. Even if you
are not required to establish paternity, paternity
establishment may result in financial benefits for the
child, such as Social Security dependents’ benefits,
pension benefits, veterans benefits, and possible
rights of inheritance. You can ask for child-support-
enforcement services if you want help getting
noncustodial parent to pay for health insurance or
child support for the child. To do this, call DOR at
1-800-332-2733, or go to www.mass.gov/dor and
click on Child Support. The child’s MassHealth
benefits will not be affected if you choose to ask for
these services or not. If you ask for these services,
you will have to cooperate with DOR.
3
Noncustodial Parent Information
Please provide the following information for each
child on the application who has a noncustodial
parent. We have provided space for three children
and three noncustodial parents. If you need more
room, please make a copy of this form or use a
separate piece of paper.
If you are applying for benefits for an unborn child,
you do not need to give us information about the
noncustodial parent of the unborn child at this time.
Name of Child #1
First name ___________________________________
Middle name _________________________________
Last name ___________________________________
Do any of the following apply to this child?
Adoption of this child is in process.
This child was born as a result of sexual abuse
or assault.
Cooperation, as defined on page 2, is not in
the best interest of this child (for example,
cooperation could result in serious physical or
emotional harm to me and/or the child).
4
I adopted this child as a single parent.
The noncustodial parent of this child is
deceased.
I do not know who the noncustodial parent of
this child is.
I am not married to the father of this child AND
I am currently pregnant.
If you checked any of the boxes above, you do
not have to provide information for this child’s
noncustodial parent. Please provide noncustodial
parent information for any other child(ren) and sign
at the end of this form.
Name of noncustodial parent for Child #1
I do not know
First name ___________________________________
Middle name _________________________________
Last name ___________________________________
Noncustodial parent’s relationship to child
Mother
Father
Gender
M
F
Date of birth (mm/dd/yyyy) ___ / ___ / ______
I do not know
5
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