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Prequalification Form
Are you currently receiving a monthly payment from MassHealth?
YES
NO
PREFER NOT TO SAY
How old is the person receiving care?
UNDER 16
16 OR OLDER
Who is the care for?
MYSELF
SOMEONE ELSE
Do You have MassHealth Standard or MassHealth CommonHealth Insurance?
YES
NO
I DON’T KNOW
Do you have someone living at home willing to provide care?
YES
NOT NOW, BUT MAYBE SOON
NO, NOT POSSIBLE AT ALL
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
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
Does the person you are caring for have MassHealth Standard or MassHealth CommonHealth Insurance?
YES
NO
I DON’T KNOW
Do you live in the same home as the person requiring care?
YES
NOT NOW, BUT MAYBE SOON
NO, NOT POSSIBLE AT ALL
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
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
You may qualify for assistance! To get started, please provide us with your full name and hit enter/return to proceed to the next page:
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Last
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How would you like to be contacted (please check all that apply and hit enter/return to proceed to the next page):
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PHONE
EMAIL
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Email
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