Important Documents and Forms
Plan Documents — Learn about your coverage and benefits.
Archived Plan Documents — Access documents for plans that are no longer offered, such as Commonwealth Care and Commonwealth Choice.
Health Needs Assessment — Complete this online form about your health history, so that we can share tools and offer support to help you meet your personal health goals. You can also call our Customer Care Center to have the assessment sent to you.
Boston Medical Center Authorization to Obtain Protected Health Information — This document lets Boston Medical Center request your protected health information from another provider.
Personal Representative Designation Request Form — This document lets you name someone you know and trust to make healthcare decisions for you if, for any reason, you become unable to make decisions or communicate your wishes to doctors.
Revocation of Personal Representative Form — This document lets you remove a previously assigned representative from making important healthcare decisions for you.
Request for Access to Information Form — This form is used to request a copy of your member information from BMC HealthNet Plan. Your information includes but is not limited to your medical claims, pharmacy claims, co-payments, case management, vision claims and behavioral health claims. The record does not include your medical records.
Request for Release of Information Form — This form is used to authorize BMC HealthNet Plan to release your Protected Health Information to your or to another organization. BMC HealthNet Plan is a Managed Care Organization (MCO), not a medical provider. Requests for medical records must be directed to your medical providers.
Request for Revocation of Release of Information Form — This document lets you remove a previously authorized person or organization from receiving your Protected Health Information.
Healthcare Proxy — A Healthcare Proxy form lets you name someone to make decisions about your medical care if you can no longer speak for yourself. This form is prepared by Massachusetts Health Decisions.