Complete and sign the Individual Application/Change Form, including the sections pertaining to the Individual Health Statement and Underwriting Authorization. (Be sure to select a Primary Care Physician (PCP) for each family member applying for coverage.)
All applicants must sign. Applicants under age 18 must have a parent/guardian’s signature.
Enclose a check for the first month’s premium, payable to ConnectiCare, with the application.
Acceptance into the plan is based on the applicant meeting the eligibility requirements and underwriting criteria, and on our review of the Individual Health Statement(s).
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ConnectiCare, Inc. and Affiliates
Attn: Billing/EFT
175 Scott Swamp Road
Farmington, CT 06032-312
Once we have processed the request, we will notify the member of the effective date. Members can apply for EFT when submitting their application or anytime after they are accepted as a member.
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