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AFC / GAFC Referral Form
Print this page, complete it by hand, and return it by secure fax. Use this version when you need to send clinical documentation — diagnoses, medication lists, or MassHealth identification numbers — which must never go through a web form or general email. To send a referral without clinical detail, use the online form instead.
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New England Healthcare Solutions LLC
1985 Main Street, Suite 207, Springfield, MA 01103 · (413) 784-5099 · referrals@nehcsolutions.com
Secure fax: (888) 801-3216
Response within one business day
Adult Foster Care / Group Adult Foster Care Referral
1 · Program referred to
Adult Foster Care — Age 16 or older
Group Adult Foster Care — Age 22 or older
Not sure — please advise
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; approval is not guaranteed.
2 · Member information
Member name
Date of birth
Phone
Best time to call
Street address
City / town
ZIP
MassHealth plan
e.g. Standard, CommonHealth, MCO or ACO name
MassHealth ID
Fax only — do not send by email
Primary language / interpreter needed
Tell us if the family needs Spanish or another language
3 · Family contact and proposed caregiver
Contact name
Relationship to member
Contact phone
Contact email
Proposed AFC caregiver (if any) and relationship
Not the member's spouse or legal guardian
Proposed caregiver already lives with the member
Member lives in senior or supportive housing
4 · Care needs
Check each activity of daily living where the member needs physical assistance, cueing, or supervision.
Bathing
Dressing
Toileting
Mobility / transfers
Eating
Medication reminders
Grooming
Supervision for safety
Meal preparation
Relevant diagnoses
Fax only
Recent hospitalization / discharge date
Primary care provider and phone
5 · Referring provider
Your name
Role / title
Organization
Phone
Email
Date of referral
The member or their authorized representative is aware of this referral and consents to being contacted.
Signature
Date