One Care IC Application Form.docx

Implementation Council for One Care Application Form Before You Begin Thank you for your interest in serving on the One Care Implementation Council.

The Council works in partnership with MassHealth toward our common goal of improving the One Care program. Through this constructive working relationship, Council members help ensure the voices of members, families, and community partners are reflected in program decisions. We are looking for people who can bring their own experiences and perspectives to the Council while also considering the diverse needs and experiences of the broader One Care community.

To apply, please submit this completed application.

Application deadline: November 2, 2026, at 5:00 PM.

Section 1: About You Name:

Job Title (if applicable):

Organization (if applicable):

Home Address:

City, State, ZIP:

Phone:

Email:

Preferred phone type:☐ Voice☐ Videophone☐ TTY Preferred communication method:☐ Email☐ Mail☐ Phone Section 2: Tell Us About Yourself Why are you interested in serving on the Implementation Council?

Tell us about your experience, skills, education, work, or lived experience that would help you contribute. If applicable, include your experience with or knowledge of One Care.

Community Engagement Tell us about your experience working with, supporting, or engaging people or communities.

Working with Diverse Communities Describe your experience working with people from different backgrounds or communities. This may include people with disabilities, Deaf or Hard of Hearing communities, blind or visually impaired people, LGBTQ+ communities, people experiencing homelessness, or other populations. We welcome a wide range of experiences and perspectives.

Section 3: Which Best Describes You?

Criterion 1: MassHealth Member or Family Member ☐ I am a MassHealth member with a disability.

☐ I am a family member or guardian of a One Care member.

If applicable, check all that apply:

☐ Physical disabilities ☐ Intellectual or developmental disabilities ☐ Serious mental illness ☐ Substance use disorder ☐ Multiple chronic illnesses or functional/cognitive limitations ☐ Homelessness

Criterion 2A: Community-Based or Consumer Advocacy Organization ☐ I represent a community-based or consumer advocacy organization.

Organization:

Criterion 2B: Provider or Trade Association

☐ I represent a provider or trade association.

Provider Type: ☐ Medical ☐ Behavioral Health ☐ Long-Term Services and Supports

Populations served (check all that apply):

☐ Physical disabilities ☐ Intellectual or developmental disabilities ☐ Serious mental illness ☐ Substance use disorder ☐ Multiple chronic illnesses or functional/cognitive limitations ☐ People experiencing homelessness

Do you receive compensation from this organization?

☐ Yes ☐ No Section 4: Geographic Representation Where do you live or work? Check all Massachusetts counties you know well.

☐ Barnstable ☐ Berkshire ☐ Bristol ☐ Dukes ☐ Essex ☐ Franklin ☐ Hampden ☐ Hampshire ☐ Middlesex ☐ Nantucket ☐ Norfolk ☐ Plymouth ☐ Suffolk ☐ Worcester Submit Your Application Please submit your completed application to the email or mailing address below.

Email: EOHHS-Procurement@mass.gov

Mail:

Executive Office of Health and Human Services Attn: Amy Butcher, Procurement Coordinator One Ashburton Place, 11th Floor Boston, MA 02108

Application deadline: November 2, 2026, at 5:00 PM.

Public Records Notice In submitting this application, you understand that information provided, including any voluntary self-identification as a recipient of MassHealth or Medicare coverage, may be subject to the Massachusetts Public Records Law.

I confirm that all information provided in this application is true and accurate, and that I am the person identified in this application.

Signature (electronic signature accepted):

Date: