Employers
  
  
  
  

  = Registered Users Only
Online Forms

 Forms for Employers:

Enrollment/Change Form
Student Verification Form
Disabled Dependent Form
Prescription Drug Reimbursement Claim Form
Prescription Drug Mail Pharmacy Order Form
Out-Of-Plan Reimbursement Form
CT Family Health Statement Form
Small Group Employer Application
Small Employer Group Application Addendum (Out of Area - PPO Product) Form
New Business Certification Statement
Small Group Employer Order Form
Small Group Information Change Form
Childbirth Preparation Class Reimbursement Form
Confirmation of Eligibility Form
Confidential Large Loss Prognosis Form
Small Employer Certification Form
HIPAA Authorization Form
MA Non-Discriminatory Certification
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 appropriate selection below. A description and directions for use will appear when you select a form.

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.

Form Use this form... Directions for Use
Authorization Form (Privauth Form B/E 05/05):

Connecticut Resident - Fully Insured Employers

Massachusetts Resident - Fully Insured Employers (if member is enrolling/enrolled in ConnectiCare Network USA (PPO), please use ConnectiCare Network USA (PPO))

ConnectiCare Customized - Self Funded Employers

ConnectiCare Network USA (PPO)

 If you are seeking to:
  • Add a new employee.
  • Add a dependent.
  • Remove a dependent.
  • Terminate enrollment.
  • Change plans.
  • Elect COBRA coverage.
  • Change a name or marital status.
  • Change an OB/GYN.
  • Change an address.*
  • Change a primary care physician.*
  • Order a replacement ID Card.*

* This information may also be changed online through the Member Services screens. Please direct the insured employee to this site.

 

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

  • Print the form.
  • Fill in the necessary information and obtain the subscriber's signature.
  • Make a photocopy for your office files.
  • Mail to original to ConnectiCare.
  • If you have any questions, call ConnectiCare’s Group and Membership Administration Dept. at 1-800-333-1733, Monday through Friday 9:00 a.m. – 5:00 p.m., 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.

 

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Form Use this form... Directions for Use
Student Verification Form If an employee would like to provide verification of student status.
  • Print the form.
  • Fill in the appropriate information.
  • Forward the form to the accredited institution for completion and mailing to ConnectiCare.
  • If you have any questions, call ConnectiCare’s Group and Membership Administration Dept. at 1-800-333-1733, Monday through Friday 9:00 a.m. – 5:00 p.m., Eastern Time.

 

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Form Use this form... Directions for Use
Disabled Dependent Form If an employee would like to request continuation of ConnectiCare health care coverage for a disabled dependent who has reached the maximum dependent age limit.
  • Print the form.
  • Fill in the appropriate information.
  • Forward the form to the accredited institution for completion and mailing to ConnectiCare.
  • If you have any questions, call ConnectiCare’s Group and Membership Administration Dept. at 1-800-333-1733, Monday through Friday 9:00 a.m. – 5:00 p.m., Eastern Time.

 

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Form Use this form... Directions for Use
Prescription Drug Reimbursement Claim Form If an employee would like to receive reimbursement for prescriptions that were purchased without the use of a ConnectiCare ID Card.
  • Print the form.
  • Have the employee fill in the appropriate information.
  • Have the employee attach all receipts.
  • Have the employee mail the information to: ConnectiCare, Claims Dept., P.O. Box 546, Farmington, CT 06034.
  • 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
Prescription Drug Mail Pharmacy Order Form If an employee would like to receive a 90-day supply of maintenance prescription drugs through the mail.
  • Print the form.
  • Have the employee fill in the appropriate information.
  • Have the employee attach the
    prescription(s) from the provider.
  • Have the employee enclose payment.
  • Have the employee mail the information to Express Scripts, Attn: Mail Pharmacy, 3684 Marshall Lane, Bensalem, PA 19020-5914.
  • If you have any questions, call the Express Scripts' Customer Service Call Center, available 24 hours-a-day, 365 days-a-year at 1-800-369-0675.

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Form Use this form... Directions for Use
Out-Of-Plan Reimbursement Form If an employee would like to:
  • Obtain reimbursement for a medical service that was paid for out of pocket.
  • Request payment to be made to an out-of-plan or non-participating provider from whom a medical service was provided.
  • Request coordination of benefits with a primary insurance company.
 
  • Print the form.
  • Have the employee follow the instructions for reimbursement carefully.
  • Have the employee mail this information to: ConnectiCare, P.O. Box 546, Farmington, CT 06034-0354.
  • 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
CT Family Health Statement Form If you are a Connecticut small employer group (1-50 full-time employees) and you are seeking to:
  • Enroll an employee or dependent onto an existing group.
  • Enroll your business as a new ConnectiCare group.

 

If your group is currently covered by ConnectiCare, Inc.
  • Print the form.
  • Complete the employer section, then have the employee fill in the appropriate information.
  • All questions that they 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.
  • Mail the Health Statement Form along with a completed Enrollment 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 Group and Membership Administration Dept. at 1-800-333-1733, Monday through Friday 8:00 a.m. – 5:00 p.m., Eastern Time.

If your group is not currently covered by ConnectiCare

  • Print the form.
  • Have the employees fill in the appropriate information.
  • All questions 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.
  • Any full time employees that are waiving coverage must complete the "decline" section of the Family Health Statement and sign the form. The decline section is on the front side of the form halfway down the page on the left side.
  • You must submit your form(s) with the other, required case paperwork (Small Group Employer Application) to your agent or broker who will mail it to ConnectiCare on your behalf.
  • If you do not have an agent or broker, mail the forms to: ConnectiCare, Attn: Small Group Sales Dept., 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050.
  • If you have any questions, call ConnectiCare’s Small Group Sales Dept. at 1-800-723-2986, Monday through Friday 8:00 a.m. – 4:30 p.m., Eastern Time.

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Form Use this form... Directions for Use
Small Group Employer Application If you are a small employer group (1-50 full-time employees) and you are seeking to enroll your business as a ConnectiCare group.
  • Print the form.
  • Fill out the entire form.
  • Sign the application.
  • If you have an agent or broker, he/she must complete the agent section and sign it. Your agent or broker will mail the form(s) on your behalf to ConnectiCare.
  • If you do not have an agent or broker, the paperwork can be mailed to: ConnectiCare, Attn: Small Group Sales Dept., 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050.
  • If you have any questions, call your agent/broker or ConnectiCare’s Small Group Sales Dept. at 1-800-723-2986, Monday through Friday 8:00 a.m. – 4:30 p.m., Eastern Time.

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Form Use this form... Directions for Use
New Business Certification Statement If you are a small employer group (1 – 50 full-time employees) that has been in business for at least 3 consecutive months, but has not yet filed a quarterly wage and tax statement (UC2 or UC5a), and you are seeking to enroll your business as a ConnectiCare group.
  • Print the form.
  • Complete this entire form.
  • Sign the form and have it notarized.
  • This form must be submitted to your agent or broker who will mail it to ConnectiCare on your behalf.
  • If you do not have an agent or broker, please mail this form to: ConnectiCare, Attn: Small Group Sales Dept., 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050.
  • If you have any questions, call your agent/broker or ConnectiCare’s Small Group Sales Dept. at 1-800-723-2986, Monday through Friday 8:00 a.m. – 4:30 p.m., Eastern Time.

 

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Form Use this form... Directions for Use
Small Group Employer Order Form If you are a small employer group (1-50 full-time employees) and you are seeking to order supplies.
  • Print the form.
  • Complete the forms listing the items you need.
  • Mail the form to: ConnectiCare, Attn: Operations Support Dept., 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050 or fax to (860) 674-5728,
  • If you have any questions, call ConnectiCare’s Small Group Sales Dept. at 1-800-723-2986, Monday through Friday 8:00 a.m. – 4:30 p.m., Eastern Time.

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Form Use this form... Directions for Use
Childbirth Preparation Class Reimbursement Form If an employee would like to request reimbursement for a childbirth preparation class.
  • Print the form.
  • Have your employee fill in the appropriate information.
  • Have your employee be sure to attach payment receipt.
  • Have your employee mail the completed information to: ConnectiCare, Claims Dept., 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050
  • 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
Confirmation of Eligibility Form

If you are a Connecticut small employer group (1-50 full-time employees) and you are seeking to:

  • Enroll a husband/wife business filing a Schedule C form and spouse does not appear on the Schedule C form.

 
  • Print the form.
  • Complete this entire form.
  • Sign the form and have it notarized. 
  • This form must be submitted to your agent or broker who will mail it to ConnectiCare on your behalf.
  • If you do not have an agent or broker, please mail this form to: ConnectiCare, Attn: Small Group Sales Dept., 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050.
  • If you have any questions, call your agent/broker or ConnectiCare's Small Group Sales Dept. at 1-800-723-2986, Monday through Friday 8:00 a.m. - 4:30 p.m., Eastern Time.

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Form Use this form... Directions for Use
Confidential Large Loss Prognosis Form

If you are a large employer group (51+ full-time employees) and this information has been requested by a ConnectiCare representative.
  • Print the form.
  • Complete the entire form.
  • Have an authorized officer or benefits administrator sign and date the form.
  • Mail the original signed form to your agent or broker. If you do not have an agent or broker, please mail this form to your Account Executive at ConnectiCare, 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050.
  • You may fax a copy of the form to your agent, broker, or Account Executive, however, the original signed form must also be received by ConnectiCare. Fax to (860) 674-2011.

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Form Use this form... Directions for Use
Small Employer Certification Form

Connecticut

Massachusetts

If you are an employer seeking to determine if your group meets eligibility requirements.
  • Print the form. 
  • Complete the entire form. 
  • Sign the form. 
  • Please mail this form, along with all other New Small Group Case forms, to: ConnectiCare, Attn: Small Group Sales Dept., 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050.
  • If you have any questions, you can call ConnectiCare's Small Group Sales Dept. at 1-800-723-2986, Monday through Friday 8:00 a.m. - 4:30 p.m., Eastern Time.

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Form Use this form... Directions for Use
Small Employer Group Application Addendum (Out of Area - PPO Product) Form If you are a small employer group (1-50 full-time employees) and you are seeking to enroll your business as a ConnectiCare group and would like to offer ConnectiCare Network USA -PPO product to your employees.
  • Print this form in addition to the Small Group Employer Application.
  • Fill out the application and addendum completely.
  • Sign the application.
  • If you have an agent or broker, he/she must complete the agent section of the application and sign it. Your agent or broker will mail the form(s) on your behalf to ConnectiCare.
  • If you do not have an agent or broker, the paperwork can be mailed to: ConnectiCare, Attn: Small Group Sales Dept., 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050.
  • If you have any questions, call your agent/broker or ConnectiCare’s Small Group Sales Dept. at 1-800-723-2986, Monday through Friday 8:00 a.m. – 4:30 p.m., Eastern Time.

Form Use this form... Directions for Use
Authorization Form (Privauth Form B/E 05/05) If you are assisting a member with resolution of a claims or health benefit coverage issue and are seeking disclosure of the member’s protected health information as part of this process.

If you are have specific claim information (claim number or date of service, provider name, and procedure/service) and want only to know if the claim has been paid or denied you can call Member Services at 1-800-251-7722. A signed authorization form from the member is not required.

If you are seeking general benefit or eligibility information, you can call Member Services at 1-800-251-7722. A signed authorization form from the member is not required.

  • Print the form.
  • Have the subscriber fill in the appropriate information.
  • All blanks must be completed, and form must be signed and dated.
  • Fax the completed form directly to ConnectiCare to the Attention: (insert Account manager name) at 860-674-2011.
  • If you have any questions, call your Account Representative directly.

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Form Use this form... Directions for Use
Small Group Information Change Form If you are a small employer group (1-50 full-time employees) and you are seeking to make changes to the group address, contact, or to terminate a ConnectiCare group.
  • Print the form.
  • Fill out the appropriate section of the form.
  • Sign the Form, including Title of person Signing..
  • Mail the forms to: ConnectiCare, Attn: Small Group Billing, 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050
If you have any questions, call ConnectiCare's Small Group Billing Dept. at 1-800-333-1733, Monday through Friday 8:00 a.m. - 4:30 p.m., Eastern Time

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Form Use this form... Directions for Use
MA Non-Discriminatory Certification

For employer groups with a Massachusetts location to prove that the employer group is offering group health benefit plans on a non-discriminatory basis to all of their full-time employees who live in Massachusetts.

This form must be submitted for all new groups and renewing groups at their renewal.

  • Print the form.
  • Have the client fill in appropriate information, sign, date and submit to ConnectiCare.

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