Get Ma Mbr-1 2011

This guide provides clear and supportive instructions for filling out the Medical Benefit Request (MBR-1) form online. With step-by-step guidance, you will be equipped to complete the application accurately and efficiently.

Follow the steps to successfully complete your MBR-1 application.

1. Click ‘Get Form’ button to access the MBR-1 document. This action allows you to open the form in a suitable editor for online completion.
2. Begin with the 'Head of Household' section. Fill in your last name, first name, middle initial, street address, and mailing address, if different. Ensure to indicate whether you are applying and your U.S. citizenship status.
3. Proceed to 'Other Family Members'. List each individual in your household, their relationship to the head of household, birthdate, gender, and citizenship status. Note that you should not repeat information from the head of household.
4. In the 'Working Income' section, each family member 19 years or older who has income must provide details about their employment status and earnings. Include employer information where applicable.
5. Continue with the 'Nonworking Income' section, disclosing any additional income sources such as unemployment benefits or alimony. Each family member’s income should be detailed separately.
6. Fill out the 'Health Insurance' section on the relevant page, providing information about any current and potential health insurance coverage.
7. Complete the 'Injury, Illness, or Disability' section if applicable, ensuring to answer all questions thoroughly.
8. Review that all sections are fully completed, paying special attention to any required signatures or additional documents needed, such as proof of income and identity.
9. Once the form is filled out, print a copy. Remember to sign and date the application on page 6.
10. Finally, after printing, click the 'Clear entire form' button at the bottom of page 6 to remove your personal data from the online editor before closing.

Complete your MA MBR-1 application online today to ensure you receive the health benefits you qualify for.