Maximus - MassHealth Customer Service Center

Fill out the form fields below to register for an account.

Please note that all fields marked with an asterisk (*) are required.

Properties

Account

First Name: *

Middle Name:

Last Name: *

Avatar:

Email Address: *

Username: *

Password: *

Confirm by entering again:

Local Timezone: *

Contact

Provider Name: *

Street Address: *

City: *

State: *

Zip Code:

Phone Number: *

Provider

Provider ID: *

If you are not an enrolled MassHealth Provider Please enter "Not Enrolled" or "Application Pending" as appropriate.

Provider Type: *

Provider Association: *

Job Function:

Other

County:

Primary PID:

Secondary PID:

Additional PID:

How many additional PIDs do you represent?:

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