How to Fill Out and Submit the MassHealth Proof of Residency Affidavit

The MassHealth proof of residency affidavit is a sworn one-page form you use to prove you live in Massachusetts when you cannot provide a lease, mortgage record, utility bill, or any of the other standard address documents MassHealth normally accepts. You download it from Mass.gov, fill in your identifying information, sign it under the pains and penalties of perjury, and send it to MassHealth by mail, fax, or online upload along with a copy of the verification request letter MassHealth sent you.¹ It does not need to be notarized.²

When This Affidavit Is the Right Form

Every MassHealth applicant has to prove Massachusetts residency. The governing regulation, 130 CMR 503.002, lists ten acceptable types of proof, including mortgage records, utility bills, and school enrollment records. The affidavit is the last option on that list, meant for people who cannot produce any of the other nine.³

You are the typical candidate for this form if you are staying with a friend or family member and your name is not on any lease or bill at that address, if you are in an emergency shelter or transitional housing, if you recently arrived in Massachusetts and have not built up a paper trail yet, or if you have no fixed address. One alternative worth knowing about: a written statement from a homeless shelter director can satisfy the residency requirement on its own, so if a shelter is willing to provide that, you may not need the affidavit at all.³

Where to Get the Form

The official “Affidavit to Verify Massachusetts Residency” is a free PDF on Mass.gov.¹ Paper copies are available at any MassHealth Enrollment Center. If you applied through the Massachusetts Health Connector, the same form is referenced on the Connector’s verification documents page.²

How to Fill It Out

The form asks for a short set of identifying details and a sworn statement about where you live.

Full legal name, exactly as it appears on your MassHealth application.
Social Security number, if you have one. The field is marked “if applicable,” so applicants without an SSN leave it blank.⁴
Date of birth in month/day/year format.
MassHealth member ID, also marked “if applicable.” Include it if MassHealth has already assigned one, because it links the form to your case file. New applicants without an ID can skip it.
The residency declaration itself, which states that you live in Massachusetts and are not here just to visit for personal pleasure or to receive medical care outside of a nursing facility. The regulation requires that specific language.³
Your signature and the date. Signing attests under the pains and penalties of perjury that everything on the form is true.

If someone else can confirm your living situation — a landlord, the person whose home you are staying in, or a shelter worker — they can sign a separate statement or co-sign the affidavit to vouch for your address. When a private individual vouches for you, attach a copy of their own residency proof, such as a utility bill dated within the last 60 days or a lease. The 60-day standard tracks the regulation’s rule for utility bills submitted as primary residency proof.³

What to Send With It

The form’s own instructions tell you to include a copy of the verification request letter MassHealth sent you. That letter ties the affidavit to your open case.¹ Attach any supplementary evidence you can. Documents that would not qualify on their own, such as a piece of mail with your name and Massachusetts address, a library card, or a pay stub from a local employer, still reinforce the sworn statement and cut down on follow-up requests.

If you are mailing or faxing, use the official MassHealth Health Coverage Mail/Fax Cover Sheet, available on Mass.gov. The cover sheet asks for your name and member ID and routes your packet to the right processing queue.⁵

How to Submit It

You have three channels. Pick one. Sending the same documents through more than one channel creates duplicate records in your case file and can slow the review down.⁶

By mail: Health Insurance Processing Center, PO Box 4405, Taunton, MA 02780. Do not mail documents to a MassHealth Enrollment Center; the enrollment centers do not process mailed verifications.⁷
By fax: (857) 323-8300 for standard MassHealth and mixed-household applications. For long-term-care or SACA-2 applications, use (617) 887-8799 instead.⁵
Online: sign in to your Massachusetts Health Connector account, open the Documents section, and click Upload Documents. Accepted formats are PDF, JPEG, PNG, BMP, GIF, and TIFF, with a 5 MB cap per file. Use the Document Description dropdown to label the file as proof of residency, then click Upload Documents to finalize.⁶

What Happens Next

A caseworker reviews the affidavit against your application. Federal rules give the state a hard outer limit of 45 calendar days to issue an eligibility decision for most applicants and 90 days for disability-based applications.⁸ Those windows cover the whole eligibility decision, not just residency, but they give you a sense of how long a quiet period is reasonable.

If anything is missing, MassHealth will send a written request for the additional information. You generally have 30 days from the date of that request to respond. Miss the deadline and MassHealth can deny the application, but if you submit the missing documents within 30 days after the denial, MassHealth treats that submission date as a new application date, so you do not start from zero.⁹

The decision comes by mail as a formal eligibility notice. You can also check status by calling MassHealth Customer Service at (800) 841-2900 or by signing into your Health Connector account.¹⁰

If MassHealth Denies the Residency Verification

You can request a fair hearing. In Massachusetts, the deadline is 60 calendar days from the date you received the denial notice. If MassHealth never sent a written notice or failed to act on your application, the deadline stretches to 120 calendar days from the date the action or inaction occurred.¹¹

File the request one of four ways:

Mail the completed Fair Hearing Request Form and a copy of your denial notice to the Board of Hearings, Office of Medicaid, 100 Hancock Street, 6th Floor, Quincy, MA 02171.
Fax it to (617) 887-8797.
Email it to boh-fairhearingsrequest@mass.gov.
Call MassHealth Customer Service at (800) 841-2900 to complete the request by phone.¹¹

If the hearing officer rules in your favor, MassHealth must restore eligibility back to the date of the incorrect denial.¹²

A Note on the Perjury Clause

The affidavit is signed under the pains and penalties of perjury. Under Massachusetts law, a false sworn statement signed this way carries the same penalties as perjury committed under oath in court. Providing false residency information to get MassHealth coverage can also trigger loss of benefits and a demand to repay the healthcare costs the state covered based on the false information. The required language about not visiting Massachusetts for personal pleasure or to receive medical care is there because the regulation draws a hard line between residents and visitors.³

1
Mass.gov. Affidavit to Verify Massachusetts Residency
2
Massachusetts Health Connector. Verification Documents
3
Legal Information Institute. 130 CMR 503.002 – Residence Requirements
4
MassLegalServices. Affidavit for Proof of Massachusetts Residency for Health Coverage
5
Mass.gov. Health Coverage Mail/Fax Cover Sheet
6
Massachusetts Health Connector. Upload Documents (Proof)
7
Mass.gov. Contact MassHealth – Information for Members
8
eCFR. 42 CFR 435.912 – Timely Determination of Eligibility
9
Mass.gov. Summary of Evidence
10
Mass.gov. MassHealth
11
Mass.gov. Fair Hearing Request Form
12
Medicaid.gov. Understanding Medicaid Fair Hearings