Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering the consumer’s information at the top of the form. Fill in the consumer’s name, consumer number, street address, phone number, city, state, and zip code.
3. Indicate the Employee/PCA start date, which is when the Employee/PCA began or will begin working.
4. Select the appropriate option by checking one of the boxes for Masshealth, SCO, or Self-Direct.
5. If applicable, provide the surrogate’s information, including their name, street address, phone number, city, state, and zip code.
6. Next, complete the Employee/PCA’s information section. Fill in the name, birth date, street address, city, state, zip code, home phone number, cell phone number, email address, and social security number.
7. Lastly, ensure that all information is accurate and complete. After reviewing, save your changes, then you can download, print, or share the completed form.

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