How do I submit this form?
MASSHEALTH
Signature/Legal guardian
SECTION 7
 Mail your form to:
Permission to Share
Fill out the following section if this form is being filled
Health Insurance Processing Center
Information (PSI) Form
out by someone who has the legal authority to act on
P.O. Box 4405
behalf of the applicant or member (such as the parent
Taunton, MA 02780
of a minor child, an eligibility representative, or a
 Fax your form to:
legal guardian).
 Use this form if you want MassHealth to
share the information we have about you with
(857) 323-8300
another person or organization, such as
Printed name of person filling out this form
 If you are authorizing only specific information
• a family member, friend, or other relative;
to be shared (such as your claims information or
• someone who helps take care of you;
application file), and have checked off the second,
• someone who helps you fill out MassHealth
Signature of person filling out this form
third, or fourth box in Section 2, send the PSI to
forms; or
Privacy Office
• a social worker, lawyer, or health care
Date
600 Washington Street
advocacy group.
Boston, MA 02111
 Do not use this form if you want
Address
• information about yourself;
• information about your children under age
18 (You can usually get this without filling
Telephone number
out any forms.); or
• your eligibility and payment information
Authority of person filling out this form to act on
to be shared with your health care
behalf of the applicant or member:*
provider. (Your health care provider can
get information about your MassHealth
eligibility and payment for services provided
* If this form is being filled out by someone who has been
to you without you filling out any forms.)
appointed by a court as a legal guardian or conservator,
or who has power of attorney or health care proxy, a
 Important: If you decide that you do need to
copy of the applicable legal document must be attached.
fill out this form, you must fill out all sections
completely. Please print clearly.
PSI (Rev. 11/18)
How do I submit this form?
MASSHEALTH
Signature/Legal guardian
SECTION 7
 Mail your form to:
Permission to Share
Fill out the following section if this form is being filled
Health Insurance Processing Center
Information (PSI) Form
out by someone who has the legal authority to act on
P.O. Box 4405
behalf of the applicant or member (such as the parent
Taunton, MA 02780
of a minor child, an eligibility representative, or a
 Fax your form to:
legal guardian).
 Use this form if you want MassHealth to
share the information we have about you with
(857) 323-8300
another person or organization, such as
Printed name of person filling out this form
 If you are authorizing only specific information
• a family member, friend, or other relative;
to be shared (such as your claims information or
• someone who helps take care of you;
application file), and have checked off the second,
• someone who helps you fill out MassHealth
Signature of person filling out this form
third, or fourth box in Section 2, send the PSI to
forms; or
Privacy Office
• a social worker, lawyer, or health care
Date
600 Washington Street
advocacy group.
Boston, MA 02111
 Do not use this form if you want
Address
• information about yourself;
• information about your children under age
18 (You can usually get this without filling
Telephone number
out any forms.); or
• your eligibility and payment information
Authority of person filling out this form to act on
to be shared with your health care
behalf of the applicant or member:*
provider. (Your health care provider can
get information about your MassHealth
eligibility and payment for services provided
* If this form is being filled out by someone who has been
to you without you filling out any forms.)
appointed by a court as a legal guardian or conservator,
or who has power of attorney or health care proxy, a
 Important: If you decide that you do need to
copy of the applicable legal document must be attached.
fill out this form, you must fill out all sections
completely. Please print clearly.
PSI (Rev. 11/18)
Name of MassHealth
Why do you want us to
SECTION 1
a summary of my MassHealth claims from
SECTION 4
applicant or member
share your information?
_________________ to _________________
(month/year)
(month/year)
Permission is given for MassHealth and its
Tell us why you want to share the information listed
MassHealth’s file containing my applications and
representatives to share information listed in
in Section 2. If you leave this section blank, we will
related information
Section 2 about
assume you mean “at my request.”
other (please be specific) :
(name of applicant or member whose information is
to be shared)
End of permission
SECTION 5
Street
By giving MassHealth this permission to share
This PSI will end in 18 months unless you specify an
information, are you also giving MassHealth
end date here.
City/State/Zip
permission to share drug and alcohol treatment
information?
Your signature
SECTION 6
Yes. Share drug and alcohol treatment
Date of birth
Telephone number
information.
No. Do not share drug and alcohol treatment
I understand the following.
MassHealth ID number
information.
• When the person or organization named in
Please Note: If you do not have a MassHealth ID
Section 3 gets this information from MassHealth,
number, please use your social security number, if one
Whom do you want us to
SECTION 3
that person or organization may be able to share it
has been issued, unless you are applying for or getting
share information with?
with others without my permission. If they do so,
only MassHealth Limited, Children’s Medical Security
federal and state privacy laws may not protect the
Plan (CMSP), or Healthy Start benefits.
List the name of ONLY ONE person or organization
information.
in this section. You must fill out another PSI form
• I need to send this PSI to the appropriate address
What information do you
SECTION 2
if you want to name more than one person or
on the back page of this brochure.
want shared?
organization.
• I may cancel this permission at any time by
MassHealth may share the information listed in
sending a letter to Privacy Office,
Check the box or boxes that apply.
Section 2 with
600 Washington Street, Boston, MA 02111.
I am giving MassHealth permission to share
• If I cancel this permission, MassHealth cannot
eligibility notices and information about eligibility
take back any information that it shared when it
Name of person or organization
for, and access to, MassHealth benefits, with
had my permission to do so.
the person or organization listed in Section 3.
• If I do not give MassHealth permission to share
Please note such notices may contain financial
In care of (name of person in organization to whom
information, or if I cancel my permission to share
information. Check this box only if you want the
mail should be sent)
information with the person or organization named
person or organization in Section 3 to be able to
in Section 3, my MassHealth benefits will not be
contact MassHealth to get eligibility information
affected in any way.
and copies of your eligibility notices.
Street
• In certain circumstances, MassHealth may not
Please Note: Eligibility notices include
honor my request to share information.
information about all members of a household. If
City/State/Zip
you check this box, a separate PSI form must be
submitted and signed by each member of your
Name of applicant or member
household who is 18 years or older. If we do not get
Telephone number
forms signed by each member of your household
who is 18 years or older, we will not be able to
Signature of applicant or member
Date
honor your request.
(See other side.)