Get Ma Psi Form

The MA PSI Form allows you to authorize the Casualty Recovery Unit to share your information with other individuals or organizations. This guide provides clear and step-by-step instructions for completing the form online, ensuring a smooth and efficient process.

Follow the steps to successfully complete the MA PSI Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor. You will be able to start filling it out in your preferred format.
2. In Section 1, enter the name of the MassHealth member whose information will be shared, along with their street address, city, state, zip code, date of birth, telephone number, and MassHealth ID number. If they do not have a MassHealth ID number, provide their social security number.
3. In Section 2, indicate the specific information you want to share by checking the appropriate boxes. Be sure to specify the dates for the MassHealth claims information you wish to share, if applicable, and indicate whether you want to share drug and alcohol treatment information.
4. In Section 3, list the name of the person or organization you want the information shared with. Ensure that you include the complete contact details, including their address and phone number.
5. In Section 4, provide a reason for sharing your information. If you leave this section blank, it will be assumed you are sharing it 'at your request'.
6. In Section 5, specify an end date for permission if you do not want it to expire in 18 months. If left blank, the permission will last for the full 18 months.
7. In Section 6, review the information provided, sign the form, and print the name of the MassHealth member. If applicable, have the legal guardian fill out the signature section.
8. In Section 7, if someone other than the member is filling out the form, that individual must provide their name, signature, date, address, and telephone number. Attach any legal documents if necessary.
9. Once all sections are completed, save your changes. You can then download, print, or share the form as needed.

Complete your MA PSI Form online today to ensure your information is shared efficiently.