Providers
Provider 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.

Claims Payment:
  • Adjustments/Corrected Claims Request Form
  • Claim Status Request Form
  • Electronic Funds Transfer Authorization
  • Provider Appeal Request Form
  • Standard Provider Refund Form
    Health Management:
  • Health Screening Checklist
  • Medication List
  • Podiatric Fax Back Form
  • Problem List
  • Adult Patient Summary
  • Asthma Control Plan
    Medical Pre-Authorization:
  • Continuation of Authorization for IV Therapy
  • Continuation of Home Health
  • Eastern Rehabilitation Fax Cover Sheet
  • Pre-authorization Form: Infertility Therapy
  • Obstetrical Pre-certification Form
  • Ophthalmology/Optometrist Fax Back Form
    Pharmacy Pre-Authorization:
  • Pharmacy Pre-authorization Form: General Requests
  • Pharmacy Pre-authorization Form: Antidepressants
  • Pharmacy Pre-authorization Form: Celebrex
  • Pharmacy Pre-Authorization Form: Non-Sedating Antihistamine
  • Pharmacy Pre-authorization Form: Physician Administered Drugs
  • Pharmacy Pre-authorization Form: Proton Pump Inhibitors
  • Pharmacy Pre-authorization form: Statin Medications
  • Pre-authorization Form: Infertility Therapy
    Other Forms:
  • Advance Health Care Directives
  • Disabled Dependent Form
  • Credentialing Data Form
  • Supply Reorder Form
  • W-9 Request for Taxpayer Identification Number and Certification

    Form Use this form... Directions for Use
    Adjustments/Corrected Claims Request Form Use this form to provide us with the required information to process your request for an adjusted or corrected claim.
    • Print the form
    • Fill in the appropriate information
    • Mail the completed form to ConnectiCare, Attn: Claim-Adjustments/Corrected Claims, 175 Scott Swamp Road, Farmington, CT. 06032-3124 or fax to: 1-860-409-2455.
    • If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. - 5:00 p.m., Eastern Time

     

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    Form Use this form... Directions for Use
    Claim Status Request Form To request status on a claim.
    • Print the form.
    • Fill in the appropriate information.
    • Fax the completed form to Provider Services at (860) 674-7035.
    • If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. – 5:00 p.m., Eastern Time.

     

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    Form Use this form... Directions for Use
    Electronic Funds Transfer Authorization If you would like to request your payment directly into your bank account on the same day we issue reimbursement check.
    • Print the form.
    • Complete the entire form.
    • Mail to the Finance Department; Attn: Electronic Funds Transfer; ConnectiCare, Inc.; 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050
    • Or fax to (860) 674-2215.
    • If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. – 5:00 p.m., Eastern Time.

     

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    Form Use this form... Directions for Use
    Provider Appeal Request Form If you would like to request reconsideration of a claim that was denied for administrative purposes (e.g., filing limit, coding edits).
    • Print the form.
    • Fill in the appropriate information.
    • Fax the completed form to the Provider Appeals Coordinator (860) 674-7035 or mail to ConnectiCare, Attn: Provider Appeals Coordinator, 175 Scott Swamp Road, Farmington, CT. 06032-3124.
    • If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. - 5:00 p.m., Eastern Time.

     

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    Form Use this form... Directions for Use
    Standard Provider Refund Form If you need to make a refund back to ConnectiCare due to an overpayment.
    • Print the form
    • Fill out the appropriate information
    • Mail to ConnectiCare, Inc., P.O. Box 32153, Hartford, CT 06150-2153
    • If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. - 5:00 p.m., Eastern time

     

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    Form Use this form... Directions for Use
    Health Screening Checklist To document information for patient files.
    • Print the form.
    • Fill out appropriate information and place in the patient’s file.

     

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    Form Use this form... Directions for Use
    Medication List To document information for patient files.
    • Print the form.
    • Fill out appropriate information and place in the patient's file.

     

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    Form Use this form... Directions for Use
    Podiatric Fax Back Form When you see a patient with diabetes please complete the fax back form
    • Print the form.
    • Fill out appropriate information
    • Fax to the patients PCP using the fax back cover sheet.

     

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    Form Use this form... Directions for Use
    Problem List To document information for patient files.
    • Print the form.
    • Fill out appropriate information and place in the patient's file.

     

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    Form Use this form... Directions for Use
    Adult Patient Summary To document information for patient files.
    • Print the form.
    • Fill out appropriate information and place in the patient's file.

     

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    Form Use this form... Directions for Use
    Asthma Control Plan If you are seeking to design an Asthma Treatment Plan with your patient.
    • Print the form.
    • Use for developing an Asthma Treatment Plan.
    • Have your patient keep the asthma plan available for easy reference.
    • If your patient would like additional information about asthma, or would like to enroll in a free Asthma Education class where they will receive a peak flow meter, a video, and educational materials, please have them call 1-800-390-3522.
    • If 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.

     

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    Form Use this form... Directions for Use
    Continuation of Authorization for IV Therapy Request Form If you are seeking to obtain authorization of additional IV therapy beyond the dates approved for the initial authorization.
    • Print the form.
    • Fill in the appropriate information.
    • Fax the completed form to ConnectiCare's Medical Management team at (860) 409-2437. Please use a cover sheet to protect transmission of PHI.
    • If you have any questions, call Provider Services at 1-800-828-3407

     

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    Form Use this form... Directions for Use
    Continuation of Home Health Care Authorization Request Form If you are seeking to obtain authorization of additional home health care beyond the dates approved for the initial authorization.
    • Print the form.
    • Fill in the appropriate information.
    • Fax the completed form to ConnectiCare's Medical Management team at (860) 409-2437. Please use a cover sheet to protect transmission of PHI.
    • If you have any questions, call provider Services at 1-800-828-3407

     

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    Form Use this form... Directions for Use
    Eastern Rehabilitation Fax Cover Sheet

    ConnectiCare, Inc. or ConnectiCare Customized (Commercial)

    ConnectiCare Medicare VIP Plans (Medicare)

    		If you are an outpatient rehabilitation service provider requesting services for a member who has a ConnectiCare, Inc. (all members) or ConnectiCare Customized (who reside in the state of Connecticut), use this form to fax your initial evaluation or request for additional services.
    • Print the cover sheet.
    • Complete the entire form.
    • Attach the complete evaluation for all requested services
    • Fax the form and evaluation to 1-860-667-8259
    • If you have any questions, call Provider Services at 1-800-828-3407, Monday through Thursday 8:00 am - 5:00 pm and Friday 9:00 am - 5:00 pm, Eastern time

     

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    Form Use this form... Directions for Use
    Pre-authorization Form: Infertility Therapy If you are seeking to obtain authorization for infertility therapy, including infertility prescription drug requests.
    • Print or save form.
    • Fill in the appropriate information.
    • Fax the completed form to ConnectiCare at (860)674-5893
    • 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

     

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    Form Use this form... Directions for Use
    Obstetrical Pre-certification Form If you need to pre-certify your ConnectiCare patient for delivery.
    • Print the form.
    • Fill out the entire form.
    • Send or fax the form as indicated on the form.
    • If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. – 5:00 p.m., Eastern Time.

     

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    Form Use this form... Directions for Use
    Ophthalmology / Optometrist Fax Back Form When you see a patient with diabetes please complete the fax back form
    • Print the form.
    • Fill out appropriate information
    • Fax to the patients PCP using the fax back cover sheet.

     

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    Form Use this form... Directions for Use
    Pharmacy Pre-authorization Form: General Requests If you are seeking to obtain authorization for medications other than certain specific drugs that require their own form, as listed above.
    • Print the form.
    • Fill in the appropriate information.
    • Fax the completed form to Pharmacy Services (860) 674-2851 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050.
    • If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. – 5:00 p.m., Eastern Time.

     

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    Form Use this form... Directions for Use
    Pharmacy Pre-Authorization Form: Anitdepressants If you are seeking to obtain authorization for antidepressant medications.
    • Print the form.
    • Fill in the appropriate information.
    • Fax the completed form to Pharmacy Services (860) 674-2851 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT 06032-3124.
    • 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.

     

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    Form Use this form... Directions for Use
    Pharmacy Pre-authorization Form: Celebrex If you are seeking to obtain authorization for Celebrex medication.
    • Print or save form.
    • Fill in the appropriate information.
    • Fx the completed form to Pharmacy Services (860) 674-2851 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road. PO Box 4050 Farmington, CT 06034-4050.
    • If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. – 5:00 p.m., Eastern Time.

     

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    Form Use this form... Directions for Use
    Pharmacy Pre-Authorization Form: Non-Sedating Antihistamine If you are seeking to obtain authorization for Non-sedating Antihistamines.
    • Print or save form.
    • Fill in the appropriate information.
    • Fax the completed form to Pharmacy Services (860) 674-2851 or toll free (800) 249-1367 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT. 06032-3124.
    • 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.

     

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    Form Use this form... Directions for Use
    Pharmacy Pre-authorization Form: Physician Administered Drugs If you are seeking to obtain authorization for a physician administered drugs (e.g., injectable drugs).
    • Print or save the form.
    • Fill in the appropriate information.
    • Fax the completed form to Pharmacy Services (860) 674-2851 or toll free (800) 249-1367 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT. 06032-3124.
    • 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.

     

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    Form Use this form... Directions for Use
    Pharmacy Pre-authorization Form: Proton Pump Inhibitors If you are seeking to obtain authorization for a Proton Pump Inhibitor.
    • Print or save the form.
    • Fill in the appropriate information.
    • Fax the completed form to Pharmacy Services (860) 674-2851 or toll free (800) 249-1367 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT. 06032-3124.
    • 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.

     

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    Form Use this form... Directions for Use
    Pharmacy Pre-authorization Form: Statin Medications If you are seeking to obtain authorization for a statin medications.
    • Print or save form
    • Fill in the appropriate information
    • Fax the completed form to Pharmacy Services (860) 674-2851 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT. 06032-3124.
    • If you have any questions, 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

     

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    Form Use this form... Directions for Use
    Advance Health Care Directives If you wish to provide your patients with information on how they may go about obtaining an advance directives.
    • Print the form.

     

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    Form Use this form... Directions for Use
    Disabled Dependent Form If you would like to request continuation of ConnectiCare health care coverage on behalf of a disabled ConnectiCare dependent who has reached the maximum dependent age limit.
    • Print the form.
    • Complete the physician portion of the form.
    • Have the insured complete the appropriate information, including signature of both the insured employee and dependent.
    • Mail the completed form to ConnectiCare, Attn: Group and Membership Administration Dept., 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050 or fax to (860) 409-8991.
    • 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.

     

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    Form Use this form... Directions for Use
    Credentialing Data Form If you are looking to submit an application to participate within the ConnectiCare network of participating health care providers.
    • Print the form.
    • Fill in the appropriate information.
    • Fax the completed form, along with a W-9 form, to Network Operations at (860) 674-2849 or mail to ConnectiCare, Attn: Network Operations, 175 Scott Swamp Road, Farmington, CT 06032-3124.
    • If you have any questions, call ConnectiCare’s Provider Services Dept. at 1-800-828-3407, 8:30 a.m. to 5:00 p.m. Monday through Thursday, and 9:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

     

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    Form Use this form... Directions for Use
    Supply Reorder Form If you are seeking to obtain:
    • Allergies or NKA Stickers.
    • Chart Stickers.
    • Maternity Precertification forms.
    • Member Education Cards.
    • Personal Care Plan Financial Waiver Forms.
    • Pregnancy Loss Notification Forms.
    • Provider Refund Forms.
    • Return Self-addressed mailing Labels.

     
    • Print the form.
    • Fill in the appropriate information.
    • Mail the completed form to ConnectiCare, Network Operations Department, 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050 or fax to: 1-860-674-2849.
    • If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. – 5:00 p.m., Eastern Time.

     

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    Form Use this form... Directions for Use
    W-9 Request for Taxpayer Identification Number and Certification If you are seeking to change your Tax ID#.
    • Print the form. 
    • Complete the W-9 Form and Provider Change Form.
    • Fill in the appropriate information.
    • Mail the completed forms to ConnectiCare, Network Operations Department, 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050 or Fax to: 1-860-674-2849.
    • If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. – 5:00 p.m., Eastern Time.

     

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