MassHealth Medical Records Release Form
Commonwealth of Massachusetts
MassHealth Disability Evaluation Service
This MassHealth Medical Records Release Form is to get medical information from your health-care provider so that the MassHealth Disability
Evaluation Service (DES) can make a disability determination.
Please read the instructions carefully before you fill out this form. If you leave any sections of this form blank, this permission will not be valid, and
the health-care provider will not be able to share your information with the MassHealth DES. If the health-care provider does not share medical
information with the MassHealth DES, we will not be able to make a disability determination.
General instructions for filling out the Medical Records Release Form
You must follow these instructions when filling out the Medical Records Release Forms. The health-care providers will not send medical records to
the MassHealth DES if you do not fill out the f