DHS-6939-ENG 8-21
(1.0.1)
MA-EPD Good Cause Application
Instructions
MA-EPD ENROLLEE NAME
CASE NUMBER or MHCP MEMBER NUMBER
PHONE NUMBER
EMAIL ADDRESS
STREET ADDRESS
CITY
STATE
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
ZIP CODE
What happened that was unexpected and makes you unable to pay your MA-EPD premium?
When did this unexpected event occur?
What expenses must you pay because of the change or event?
Is there anything else you would like to tell us to help us understand your good cause request?
If this description is not complete, your application will be denied.
Submitted by
Submitter is MA-EPD Enrollee
NAME
PHONE NUMBER
EMAIL ADDRESS
ROLE
Enrollee
Authorized Representative
Case Manager
Financial Worker
Other
TODAY'S DATE
I certify that all information provided on this form is true and correct.
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