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Common Enrollment Application (pdf)
Instructions:
- How to submit the Commonwealth Choice Common Enrollment Application, Health Connector Terms & Conditions and premium payments
- How to make premium payments
- How to submit the Commonwealth Choice Common Enrollment Application, Health Connector Terms & Conditions and premium payments
Print and complete enrollment applications and Terms & Conditions. Mail both items along with your first month premium payment to:
- Commonwealth Choice
- Customer Service Center
- Attn: Linda DiPietro, Director of Administration
- 554 Main Street
- Worcester, MA 01608
OR
Print and complete enrollment application and Terms & Conditions and fax them to:
- FAX: 508-770-0102
- Attn: Linda DiPietro, Director of Administration
If you use this option, you still need to mail in your premium payment
Commonwealth Choice Customer Service must receive all of the following for your coverage to begin:
- A completed enrollment application;
- Terms & Conditions; and
- Your first month’s premium in full
The Customer Service Center must receive all three items listed above no later than 8 business days before the end of the month for coverage to begin the following month.
- How to make premium payments
Premium payments can be paid by personal check or money order. Wire transfers are available for a fee (please contact the Customer Service Center at 877-MA-ENROLL or 877-623-6765 to arrange). Persons who are hearing or speech impaired may use TTY service by calling 888-213-8163. Payments should be sent to the address listed above.
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