Get Masshealth Data Collection Form

Filling out the Masshealth Data Collection Form online is an essential step for providers seeking to engage with MassHealth services. This guide provides detailed, step-by-step instructions to help you navigate the form efficiently and accurately.

Follow the steps to complete the Masshealth Data Collection Form online.

1. Press the ‘Get Form’ button to access the Masshealth Data Collection Form and open it in your chosen editor.
2. Begin entering the required information in the ‘Provider name’ field, ensuring it accurately reflects your organization.
3. In the ‘Provider ID or application tracking number (ATN)’ field, provide your organization’s unique identifier to facilitate processing.
4. Fill in the primary user’s last name, first name, and middle initial, ensuring that the names match official documents.
5. Enter the primary user’s date of birth in the specified month and date format (MMDD) to verify identity.
6. Create a user-defined four-digit PIN in the designated field. This is a required entry for account security.
7. Provide the work zip code and the work e-mail address of the primary user for correspondence from MassHealth.
8. If applicable, enter the existing Virtual Gateway user ID to link with current accounts.
9. Provide a contact phone number for follow-up correspondence. It is important to ensure this number is accurate.
10. Select one option from the provided checkboxes indicating whether the organization is a MassHealth provider or provider applicant.
11. Choose the provider type from the available options, such as MCO, PACE, nursing facility, or billing agency.
12. Review all the information entered to ensure accuracy and completeness before proceeding.
13. Sign the form by adding the provider’s signature and the date, as signature stamps are not accepted.
14. Once completed, save your changes, and prepare to download or print the form, or share it as needed.

Complete your Masshealth Data Collection Form online today!