Home   Careers   Site Requirements     


Search powered by Google

Register Now | Forgot Password?
  • Find a Doctor
  • Pharmacy Center
  • My Plan
  • My Health
  • Estimate My Costs
  • Overview of Plans

  • Members


    • Print ID Card
    • Order ID Card

    Member Quick Tools
      Find a Doctor  
    View My Benefit Documents
    Check Claims Status
    Get a New ID Card
    Pay Solo Premium
    Update Your Profile
    Price a Drug Tool
    My Health Care Financial Summary
    Claim Pre-Estimate Form
    Treatment Cost Estimator



  • Welcome

    • Online Forms

      Member or Pharmacy Central Online Forms.

      If you need a copy of a particular form, ConnectiCare's Online Form Resource can save you time. To obtain a copy of a specific form, please click on the form by name below. A description and directions for use will appear.

      All forms are in PDF format. The freely available Adobe Acrobat Reader is required to view and print PDF files.

      All forms are the exclusive property of ConnectiCare, or used by ConnectiCare with permission, and protected by copyright. All forms are to be used solely for business with ConnectiCare.

      Enrollment/Change Form
      Connecticut Family Health Statement Form
      Disabled Dependent Form
      Prescription Drug Reimbursement Claim Form
      Prescription Drug Mail Pharmacy Order Form
      Out-Of-Plan Reimbursement Form
      Asthma Control Plan
      Childbirth Preparation Class Reimbursement Form
      Infertility Treatment and Procedures Disclosure Form
      ConnectiCare Solo Electronic Funds Transfer Form
      Cobra Election Notice Form
      Claim Pre-Estimate Form
      Request for Personal Information

      Form Use this form... Directions for Use
      Enrollment/Change Form:

      Connecticut Domiciled Group - Fully Insured Employers

      Massachusetts Domiciled Group - Fully Insured Employers

      ConnectiCare Customized - Self Funded Employers

      Please Note:
      If you are unsure as to which form to use, please consult with your Employer to obtain the correct Enrollment/Change form.

       

      		 If you are seeking to:
      1. Add a dependent.
      2. Remove a dependent.
      3. Terminate enrollment.
      4. Change plans.
      5. Elect COBRA coverage.
      6. Change your name or marital status.
      7. Change your OB/GYN.
      8. Change your address.*
      9. Change PCP*
      10. Order ID Card*

      *In most cases, this information may also be changed online through the Managing Your Account screens.

      NOTE:   In order to print this form, you must set your print properties to:

      Fit to Page if you are using Adobe Acrobat 4.0 or Shrink oversized pages to paper size if you are using Adobe Acrobat 5.0

      1. Print the form.
      2. Fill in the necessary information and sign the form.
      3. Submit the form to your employer. (Note: this form will not be accepted from the subscriber directly.)
      4. If you have any questions, call ConnectiCare’s Member Services Department at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

      Please Note:
      For small employer groups only (1-50 full-time employees) – a CT Family Health Statement Form must accompany the Enrollment/Change Form if you are a new hire, a new group, or enrolling at your annual open enrollment period. This form is not required for members enrolling in Massachusetts plans.

       

      Back to Top

      Form Use this form... Directions for Use
      Connecticut Family Health Statement Form If you are an employee of a Connecticut small employer group (Employer with 1-50 full-time employees) and you are seeking to enroll yourself or a dependent.
      1. Print the form.
      2. Fill in the appropriate information.
      3. All questions to which you have answered "yes" on the Family Health Statement Form must be explained in the space provided on the form. If additional space is needed, attach a separate piece of paper.
      4. Forward the Health Statement Form along with your completed Enrollment Form to your Benefits Office.
      5. If you have any questions regarding the Family Health Statement Form, call ConnectiCare’s Group and Membership Administration Dept. at 1-800-333-1733, Monday through Friday 8:00 a.m. – 5:00 p.m., Eastern Time.

      Back to Top

       

      Form Use this form... Directions for Use
      Disabled Dependent Form If you are a Parent or Guardian of a disabled dependent, and you are requesting that ConnectiCare health care coverage be continued for your dependent who has reached the maximum dependent age limit.
      1. Print the form.
      2. Fill in the appropriate information.
      3. Forward the form to the accredited institution for completion and mailing to ConnectiCare.
      4. If you have any questions, call ConnectiCare’s Member Services Department at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

      Back to Top

       

      Form Use this form... Directions for Use
      Prescription Drug Reimbursement Claim Form If you are seeking to receive reimbursement for prescriptions that were purchased without the use of your ConnectiCare ID Card.
      1. Print the form.
      2. Fill in the appropriate information.
      3. Attach all receipts.
      4. Mail the information to: ConnectiCare, Claims Dept., P.O. Box 546, Farmington, CT 06034.
      5. If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

      Back to Top

       

      Form Use this form... Directions for Use
      Prescription Drug Mail Pharmacy Order Form If you are seeking to order a 90-day supply of maintenance prescription drugs through the mail.
      1. Helpful Mail Order Hints
      2. Print the form.
      3. Fill in the appropriate information.
      4. Attach the prescription(s) from your provider.
      5. Enclose your payment.
      6. Mail the information to Express Scripts, Attn: Mail Pharmacy, 3684 Marshall Lane, Bensalem, PA 19020-5914. .
      7. If you have any questions, call Express Scripts' Customer Service Call Center, available 24 hours-a-day, 365 days-a-year at 1-800-369-0675

      Back to Top

       

      Form Use this form... Directions for Use
      Out-Of-Plan Reimbursement Form If you are seeking to:
      1. Obtain reimbursement for a medical service that you paid for out of your own pocket.
      2. Request payment to be made to an out-of-plan or non-participating provider from whom you received a medical service.
      3. Request coordination of benefits with your primary insurance company.

       
      1. Print the form.
      2. Follow the instructions on the form.
      3. For Medical and Surgical Claims, mail this information to:
          ConnectiCare
          P.O. Box 546
          Farmington, CT 06034-0546.

          For Mental Health and Substance Abuse Claims, please call ConnectiCare's Member Services Dept. at 1-800-251-7722, Monday through Thursday 8:00 a.m. - 5:30 p.m. and Friday 9:00 a.m. - 5:00 p.m., Eastern Time.
      4. If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

      Back to Top

       

      Form Use this form... Directions for Use
      Asthma Control Plan If you are a ConnectiCare member and you have asthma. (This tool will help your physician or asthma specialist to design a plan to control your asthma.)
      1. Print the form.
      2. Bring the form to your next appointment with your primary care physician or asthma specialist, for discussion and plan development.
      3. Keep the completed asthma plan easily available for quick reference.
      4. If you would like additional information about asthma or you have any questions, call ConnectiCare’s Health Management Programs at 1-800-390-3522, Monday through Friday 8:00 a.m. – 4:30 p.m., Eastern Time.

      Back to Top

       

      Form Use this form... Directions for Use
      Childbirth Preparation Class Reimbursement Form If you are seeking to receive reimbursement for a childbirth preparation class.
      1. Print the form.
      2. Fill in the appropriate information.
      3. Attach your payment receipt.
      4. Mail this information to: ConnectiCare, Claims Dept., 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050.
      5. If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

      Back to Top

       

      Form Use this form... Directions for Use
      Infertility Treatment and Procedures Disclosure Form
      Note: This form is located on the State of Connecticut website. When you choose this form, you are leaving ConnectiCare's website.      		 When you are seeking health insurance coverage for infertility treatment or procedures and have previously received infertility treatment or procedures for which you received coverage under a different health insurance policy.
      1. Print the form.
      2. Complete the form including signature and seal by a Notary Public.
      3. Send the original form to ConnectiCare Inc., Attention: Clinical Review at 175 Scott Swamp Road, P.O. Box 4050, Farmington, CT 06034-4050.
      4. If you have any questions, call ConnectiCare's Clinical Review department at 1-800-562-6833, Monday through Friday 8:00 a.m. - 5:00 p.m., Eastern Time.

      Back to Top

       

      Form Use this form... Directions for Use
      ConnectiCare Solo Electronic Funds Transfer Form
      		 For ConnectiCare SOLO (individual) members who wish to make their payments electronically.
      1. Print the form.
      2. Complete the entire form, sign and date.
      3. Mail the form along with a voided check or savings deposit ticket to: ConnectiCare, Inc and Affiliates, Attn: Billing/EFT, 175 Scott Swamp Road, Farmington, CT 06034-4050
      4. If you have any questions, you can call ConnectiCare's Billing Dept. at 1-800-333-1733, Monday through Friday 8:00 a.m. - 4:30 p.m., Eastern Time.

      Back to Top

       

      Form Use this form... Directions for Use
      Cobra Election Notice Form

      Connecticut

      Massachusetts       		If you are seeking COBRA coverage from your former employer.
      1. Print out the form.
      2. Complete the sections that pertain to you.
      3. Send or deliver the form to your former employer. Your former employer will complete the sections that pertain to it and will forward the form to ConnectiCare.
      4. If you have any questions you can contact ConnectiCare’s enrollment customer services at 1-800-333-1733.

      Back to Top

       

      Form Use this form... Directions for Use
      Claim Pre-Estimate Form If you are a member and you want to know how much a specific service or treatment from an in-plan or out-of plan provider will cost you.
      1. Print the form.
      2. Complete ALL fields on the form. You may print the form and bring it to your provider’s office to complete sections you are unsure of. The office staff should be able to complete the form and make sure all fields are completed correctly. If they have questions, they can call our Member Services department. Incomplete forms will be returned to you.
      3. Forward the completed form via fax to (860) 409-2455 or via mail to ConnectiCare, Inc. 175 Scott Swamp Rd. Farmington, CT 06032 ATT: Claims Pre-Estimate.
      4. If you have questions, call ConnectiCare’s Member Services Department at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

      Back to Top

       

      Form Use this form... Directions for Use
      Request for Personal Information

      NOTE: A separate form must be completed for each family member. If the member (dependent) is over the age of 18, it must be signed.       		If you are requesting protected health information, claim history, referral and authorization information.
      1. Print the form.
      2. Fill in the appropriate information.
      3. Select the documents you are looking for and the appropriate dates.
      4. Forward the completed form via fax to (860) 647-2332 or via mail to ConnectiCare, Inc. 175 Scott Swamp Rd. Farmington, CT 06032.
      5. If you have questions, call ConnectiCare’s Member Services Department at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

      Back to Top































Home | Member | Producer | Employer | Provider | Visitor

Find A Doctor •  Pharmacy Center •  About Us •  Media Center •  Legal Information •  Privacy Policy

Copyright © 2012 ConnectiCare. All Rights Reserved.

Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.