Masshealth Fax Cover Sheet
Download the document to the computer for easy use
There are more pages to preview,Read on

UCP REVIEW TEAM
MassHealth
FAX Cover Sheet

Facility Information

Head of Household (HOH) Information

Facility Name: ___________________________

Name: _____________________________________

Sender’s Phone No: ______________________

DOB: ______________________________________

Sender’s Name: _________________________

Soc. Sec. No: _______________________________

Please include this cover sheet when faxing or mailing any documents to the MassHealth UCP Review
Team.

FAX NUMBER

617-241-6005
Place a checkmark ( 9 ) in the appropriate space below identifying the attached verification(s).
____

UCP Eligibility Review Form

____

Income

____

Other ___________________________________________________________________________

This facsimile transmittal may contain information that is privileged, confidential, or exempt from disclosure under
applicable law is intended for the use of only the individual or department to which it is addressed. If you are not the
recipient, or the employee o