Client ID Page - PROPOSED

MEMBER
PHOTO

(2" x 2.5")

LAST NAME

FIRST NAME

DATE OF BIRTH

GENDER

MASSHEALTH ID #

ADMISSION DATE

SERVICE LEVEL

CONFIDENTIAL - SOCIAL SECURITY NUMBER

SOCIAL SECURITY NUMBER

This information is protected and should only be accessed by authorized personnel for legitimate business purposes.

COPY OF GOVERNMENT-ISSUED ID

Attach copy of Driver's License, State ID, or Passport

(Front)

Attach copy of ID (Back) if applicable

COPY OF MASSHEALTH CARD

Attach copy of MassHealth Card

(Both sides if applicable)

Last Updated: _________________ By: _________________

CLIENT IDENTIFICATION