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See if you qualify for a monthly payment.
Name
This field is for validation purposes and should be left unchanged.
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Are you currently receiving a monthly payment from MassHealth?
YES
NO
PREFER NOT TO SAY
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How old is the person receiving care?
UNDER 16
16 OR OLDER
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Who is the care for?
MYSELF
SOMEONE ELSE
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Do You have MassHealth Standard or MassHealth CommonHealth Insurance?
YES
NO
I DON’T KNOW
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Do you have someone living at home willing to provide care?
YES
NOT NOW, BUT MAYBE SOON
NO, NOT POSSIBLE AT ALL
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How are you related to the person taking care of you?
LEGALLY MARRIED
I AM UNDER 18 AND A PARENT OR LEGAL GUARDIAN CARES FOR ME
OTHER
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Do you require assistance with at least one (1) of the following daily activities: walking, bathing, dressing, toileting or getting up from or down to a chair, couch, bed, toilet or bathtub?
YES
NO
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Does the person you are caring for have MassHealth Standard or MassHealth CommonHealth Insurance?
YES
NO
I DON’T KNOW
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Do you live in the same home as the person requiring care?
YES
NOT NOW, BUT MAYBE SOON
NO, NOT POSSIBLE AT ALL
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How are you related to the person requiring care?
LEGALLY MARRIED
I AM A PARENT OR GUARDIAN CARING FOR MY CHILD WHO IS UNDER 18
OTHER
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Does the person requiring care need assistance with at least one (1) of the following daily activities: walking, bathing, dressing, eating, toileting or transferring (getting in or out of a bed, seat, or bathtub or on/off the toilet)?
YES
NO
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You may qualify for assistance! To get started, please provide us with your full name:
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First
Last
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How would you like to be contacted (please check all that apply):
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PHONE
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Email Address:
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