Q
Massachusetts Health Connector
IRS Authorization
Revocation Form
Use and purpose of
This form may be used by people who have authorized the Massachusetts
this form
Health Connector to use tax return information from the Internal Revenue
Service (IRS) in the Health Connector’s yearly redetermination and
renewal process.
By requesting financial assistance to help pay for health insurance—such as
Advance Premium Tax Credits (APTC), ConnectorCare, or MassHealth—you
have authorized the Health Connector to use tax return information from the
Internal Revenue Service (IRS) to determine your eligibility for financial
assistance in future years.
If you do not want the Health Connector to use your tax return information to
complete your redeterminations, you must fill out this form, which will change
your application to no longer request financial help paying for health
insurance costs.
Once this request is processed, any person on the application currently
receiving APTC, ConnectorCare, or MassHealth will lose those benefits, and
must pay full price for the health insurance plan in which they are enrolled.
People who choose to change their application to no longer request financial
assistance can undo this choice and request financial help again at any time.
How to send this request:
After reviewing and signing this form, mail the completed form to:
Attn: Privacy Officer
Massachusetts Health Connector
P.O. Box 960189
Boston, MA 02196
Or email to
ConnectorPrivac[email protected]
What happens after you
The Health Connector may contact you after receiving this request. If you
send this request?
have failed to initial any statement above or to sign, your request will be
denied. Once the request is processed and approved, your application will be
updated to no longer ask for help paying for health insurance costs and any
changes this causes will begin following the dates shown in the Health
Connector’s Policy NG-5B: Coverage Effective Dates.
Questions?
Visit
MAhealthconnector.org
or call
1-877 MA ENROLL
(1-877-623-6765)
1 of 3
or TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
Personal Information
STEP 1
Fill out the information below for the primary accountholder.
Please be sure to answer all questions and fill out all parts of this form.
First name Middle name Last Name
Home street address (No PO box) Unit or apartment number
City State ZIP code
Best phone number Date of birth
(month/day/year) Last 4 Social Security number (SSN)
STEP 2
Authorization to Change Application
Please read each statement below. If you agree with
each statement
, fill in your initials next
to each statement.
Initial here I no longer authorize the Health Connector to use my IRS information to complete my
eligibility determinations in future years during its annual redetermination process.
Initial here
Initial here
Initial here
I understand that by revoking this authorization, my application with the Health Connector will
be changed to no longer ask for financial help paying for health coverage including Advance
Premium Tax Credits (APTC), ConnectorCare, and MassHealth.
I understand that all members of my household will lose financial help by changing my
application, including any dependents on my health insurance plan and any children eligible
for coverage through MassHealth.
I understand that because I will no longer be eligible for financial help, I will need to pay full
price for any insurance I have through the Health Connector.
STEP 3
Read and sign this form.
By signing below, you agree to the following statement: I have reviewed this form and understand its content. I
revoke my authorization to the Health Connector to use my tax return information and I understand that this means
I—and any household member on my account—will lose financial help paying for health insurance costs.
Signature Date
(month/day/year)
Questions?
Visit
MAhealthconnector.org
or call
1-877 MA ENROLL
(1-877-623-6765)
2 of 3
or TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
STEP 4
Special accommodations
The information on this part of the form is not required. Not answering these does not
impact your request to the Health Connector.
OPTIONAL
If you don’t need any special accommodations, you don’t have to fill out this section.
Do you need special accommodations for us to communicate with you about this request? (Check all that apply):
☐ Sign language interpreter Which language?
☐ Foreign language interpreter Which language?
☐ Other accommodation Explain
STEP 5
Mail completed form.
Mail your completed form to:
Attn: Privacy Officer
Massachusetts Health Connector
P.O. Box 960189
Boston, MA 02196
Email: ConnectorPrivacy@state.ma.us
Questions?
Visit
MAhealthconnector.org
or call
1-877 MA ENROLL
(1-877-623-6765)
3 of 3
or TTY: 1-877-623-7773, Monday to Friday, 8:00 a.m. to 6:00 p.m.
