Commonwealth of Massachusetts
Executive Office of Health and Human Services
www.mass.gov/masshealth
CRF-1 (Rev. 10/12)
Criminal Offender Record Information (CORI) Request Form
MassHealth Customer Service has been certified by the Criminal History Systems Board for access
to conviction and pending criminal case data. As a participating or applying MassHealth provider, I
understand that a criminal record check will be conducted for conviction and pending criminal case
information only and that it will not necessarily disqualify me.
I hereby certify under the pains and penalties of perjury that the information on this form and
any attachments that I have provided, has been reviewed and is true, accurate, and complete,
to the best of my knowledge. I understand that I may be subject to civil penalties or criminal
prosecution for any falsification, omission, or concealment of any material fact contained
herein. (Signature and date stamps, or the signature of anyone other than the provider or
applicant, are not acceptable.)
Signature of provider or applicant
Last name, first name, middle name
(Please print.)
Maiden name or alias
Place of birth
(if applicable)
Date of birth
Social security number
(Required)
Mother’s maiden name
Current address
Former address
Gender:
Height Weight Eye color
M F
State driver’s license number
Note: Please attach a copy of your driver's licence so that MassHealth can validate the information you provided above.
