Member Forms

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All forms are in PDF format using Adobe Reader. All forms are the exclusive property of ConnectiCare, or used by ConnectiCare with permission, and protected by copyright.


Authorization of Representative (AOR)
An enrollee may appoint any individual to act as his or her representative. To be appointed by an enrollee, both the enrollee making the appointment and the representative accepting the appointment must sign, date, and complete an authorization form.


HIPAA Privacy Release Form 
If you would like someone other than yourself to have access to your medical records, this written authorization is required for ConnectiCare to release a member's personal health information.


Coverage Determination Form 

Y0026_122931r File and Use 01/02/2012

Use this form when requesting coverage tiering exceptions or coverage for a drug that is not listed on the plan's list of covered drugs.


Direct Debit Form 
For members who wish to have their premium payments directly debited from their bank account. 

Medicare Redetermination/Appeal Request Form 

Y0026_122930 File and Use 12/27/2011

A written request to appeal a drug or service coverage decision.


Out-of-Plan Reimbursement Form 

H3528_CCI_09_1009_103 CMS Approved 4/15/2009

Use this form when requesting reimbursement for a covered medical service that you paid out of your own pocket.


Prescription Direct Reimbursement Form 

H3528_CCI_12_9000_11 CMS Approved 10/7/11

Use this form to request reimbursement of drugs for which the member paid for out-of-pocket at the pharmacy.


Request for Accounting Disclosures 
A written request for ConnectiCare to share with the member any personal health information that ConnectiCare has shared for reasons other than to facilitate treatment, pay claims, or health plan operations.


Request for Confidential Information 
A written request for special handling of personal health information.


Request for Personal Information 
A written request to obtain personal health information that ConnectiCare has on file about the member.


H3528_13_4006_06 XX/XX/XXXX Pending CMS Approval
Last Update 5/1/2013