How to Fill Out and Submit the MassHealth Disability Supplement Form

If MassHealth has asked you to complete the MassHealth Disability Supplement form, you fill out all seven parts, sign a medical release for every provider you list, and mail or fax the packet to Disability Evaluation Services (DES) at PO Box 2796, Worcester, MA 01613-2796, or fax (774) 455-8156.¹ DES then reviews your medical evidence and decides whether you meet the state’s disability standard, which controls the MassHealth coverage type you qualify for.

Who Has to File the Supplement

MassHealth sends this form to adults 18 and older whose coverage depends on proving a disability that has not already been confirmed elsewhere. You do not need the supplement if any of the following applies to you:

The Social Security Administration has already found you disabled for SSI or SSDI.
The Massachusetts Commission for the Blind has certified you as legally blind.
You are in a Massachusetts Rehabilitation Commission training program.¹

If you have applied for Social Security disability but no decision has come through yet, you still need to complete the supplement. The state review runs on a separate track, so you don’t have to wait on the federal ruling to get coverage. DES applies a standard closely aligned with Social Security’s: whether your condition has lasted or is expected to last at least 12 months, or is expected to result in death, and whether it significantly limits your ability to work.²

Skipping the form when MassHealth has requested it isn’t a neutral choice. Without a confirmed disability, you may be assigned a less comprehensive coverage tier or denied altogether.

Where to Get the Form

The Adult Disability Supplement is a free PDF on mass.gov, on the “Applying for disability with MassHealth” page, in both standard and large-print versions.¹ MassHealth may also mail you a copy when your application triggers a disability review.

Filling Out the Form

The instructions are blunt: complete every section. Blank sections can prevent DES from making a determination, which puts your benefits at risk.² The form has an intake section plus seven numbered parts.

Personal Information

Your name, Social Security number, date of birth, address, and phone numbers go at the top. The form also asks whether you have applied for Social Security, SSI, or SSDI, and whether Social Security sent you to a doctor for an exam. If you saw one, list the doctor’s name and the date. That helps DES avoid chasing evidence Social Security already has.

Part 1: Your Health Problems

List every medical and mental health condition, along with the symptoms or pain each causes, when it started, and what medications or treatments you use. If a condition came from an accident or injury, explain what happened. Be concrete. “Back pain” tells the reviewer nothing; “can’t stand more than ten minutes, can’t lift a bag of groceries, wakes me at night” tells them what your day actually looks like. DES compares your descriptions against clinical records, so vague language weakens your case.

Part 2: Your Medical and Mental Health Providers

List every provider who has treated you for any of these conditions since they started: primary care, specialists, therapists, hospital programs. For each, put the name, the reason for the visit, and whether you saw them in the past year. DES uses this list to request your records directly, so accurate contact information matters. A missing provider means missing records.

Part 3: Where You Live

Check whether you live in a house or apartment, group home, state facility, nursing home, rehabilitation hospital, or are homeless. Your living situation tells DES what support you already have.

Part 4: What You Can Do

This is the functional limitations section, and it carries real weight. The form lists more than two dozen daily activities: dressing, bathing, housework, sitting, standing, walking, bending, lifting, remembering, using your hands, shopping, driving, handling money, and more. Check every activity your conditions make difficult. If you can walk but only a block before pain forces you to stop, say so. Reviewers are measuring the gap between what a healthy adult can do and what you can do.

Parts 5 and 6: Language and Education

Part 5 asks about your English proficiency and first language. Part 6 covers education: highest grade completed, any special education, degrees, and vocational training. These factor into the vocational analysis of whether other work exists that matches your remaining abilities.

Part 7: Your Work History

Report whether you currently work, when you stopped if you don’t, and whether a medical condition caused problems on the job. List past jobs with duties, hours per week, pay, and the reason you left. A checklist covers physical and mental tasks performed in each role: paperwork, operating machines, construction, serving people, lifting, and so on. DES uses this to assess whether you can return to any past job or adapt to different work.

The Provider Release Forms

For every provider you listed in Part 2, you must sign a separate Authorization to Release Protected Health Information form. These let DES pull your records directly. The rules are strict: each authorization must be an original, signed in black or blue ink. No copies, no stamped signatures, no pencil. A missing or improperly signed release can stop the review in its tracks.² Each authorization expires 12 months from the date you sign it.

You sign the supplement and the authorizations yourself. No doctor signature is required on the supplement. The medical evidence comes from your providers’ records, not from a physician’s sign-off on the form.

Submitting the Packet

MassHealth accepts the supplement by mail or fax only. There is no online submission portal.¹

Mail: Disability Evaluation Services (DES), PO Box 2796, Worcester, MA 01613-2796
Fax: (774) 455-8156

Send the supplement and every signed authorization together. Copy the whole packet before mailing. If DES receives an incomplete supplement, they’ll mail it back with a notice explaining what’s missing, and you have 10 business days to return a corrected version.

What Happens After You Send It

DES date-stamps your supplement on arrival and starts the review. The unit checks whether records from your listed providers give enough evidence to decide. Massachusetts law requires providers to produce requested records within 30 days.³ Record retrieval alone can take several weeks, and total processing time varies.

If your records don’t show enough, DES may schedule a consultative examination at no cost to you. DES first asks your treating physician or psychologist whether they’re willing and qualified to perform it. If your own doctor declines or isn’t available, DES arranges the exam with an independent professional.4 Missing this appointment can derail your application, so treat it as required.

When the review is finished, DES sends a written notice. If you’re approved, the determination feeds back into your MassHealth application and sets your coverage type. If you’re denied, the letter should explain why, which matters if you appeal.

If You’re Denied

You have 60 calendar days from the date you receive the denial notice to request a fair hearing with the MassHealth Board of Hearings. If you never got a written notice, or MassHealth failed to act on your application at all, the deadline stretches to 120 calendar days from the date of the action or the date you applied.⁵

You can file the Fair Hearing Request Form several ways:

Mail the form and a copy of the denial notice to the Board of Hearings, Office of Medicaid, 100 Hancock Street, 6th Floor, Quincy, MA 02171.
Fax them to (617) 887-8797.
Call MassHealth Customer Service at (800) 841-2900 (TDD/TTY: 711) to complete the form by phone.
Email them, password-encrypted, to boh-fairhearingsrequest@mass.gov.
Bring them in person to 100 Hancock Street, 6th Floor, Quincy, between 8:45 a.m. and 4:45 p.m.

If you were already receiving MassHealth benefits when the denial arrived, you may be able to keep them during the appeal. To do that, the Board of Hearings must get your request before benefits stop or within 10 calendar days of the date you received the notice, whichever is later, and you mark the choice in the “Other Information” section of the form. If you keep benefits and later lose the appeal, MassHealth may require you to repay their cost.⁶

You can request an interpreter, assistive device, or other accommodation on the same form at no charge. If someone else files the appeal for you, they must attach proof of their authority, such as a power of attorney or court appointment as personal representative.

1
Mass.gov. Applying for Disability with MassHealth
2
Mass.gov. MassHealth Adult Disability Supplement
3
Mass.gov. MassHealth Adult Disability Supplement>
4
Mass.gov. How Applications for Disability Benefits Are Processed
5
Mass.gov. How to Appeal a MassHealth Decision
6
Mass.gov. Fair Hearing Request Form