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For professionals

Submit a referral

Complete the form below and our intake team will contact the member or family within one business day, then confirm back to you. Takes about two minutes.

This form is not a secure channel. Send the member’s name, a callback number, and the general areas where they need help. Do not enter diagnoses, medication lists, Social Security numbers, or MassHealth identification numbers. Fax clinical documentation to (888) 801-3216 or use the printable form.

1Program

Program referred to

AFC requires the member and paid caregiver to live together in a private home; a spouse or legal guardian cannot be the paid caregiver. GAFC requires MassHealth Standard or CommonHealth and an approved housing setting. Eligibility is subject to MassHealth and health-plan verification.

2Member details

Optional
Optional
Optional

3Areas of need

Where does the member need physical assistance, cueing, or supervision? (required)

Select all that apply. General areas only — no diagnoses.

Do the caregiver and member live in the same home?

Required for AFC.

Housing

Relevant to GAFC.

4Referring provider

Optional

We contact the member within one business day and confirm back to you. Submitting a referral does not establish eligibility.

Prefer paper or fax?

Use the printable version when you need to send clinical documentation. Diagnoses, medication lists and MassHealth identification numbers must go by secure fax, never through a web form.

Download PDFPrintable version

Referral channels

Referral line
(413) 784-5099
Secure fax
(888) 801-3216
Response time
Within one business day

If your organization requires a business associate agreement or a secure portal, tell us and we will accommodate it.