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Resources & Tools

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:

Claim Resubmission Request Form
Claim Status Request Form
Electronic Funds Transfer Authorization
Provider Appeal Request Form
Standard Provider Refund Form

Health Management:

Adult Patient Summary
Asthma Control Plan
Health Screening Checklist
Immunization Checklist (Child/Adolescent)
Medication List
Podiatric Fax Back Form
Problem List
Vaccine Administration Record (Adult)

Medical Pre-Authorization:

Clinical Review Pre-Authorization Request Form
Home Health Care Pre-Authorization Request Form
Infertility Treatment Pre-Authorization Request Form
IV Therapy Authorization Request Form
Obstetrical Pre-Certification Form
Ophthalmology/Optometrist Fax Back Form
Out-of-Network Clinical Review Pre-Authorization Request Form
Outpatient Rehabilitation Therapy Authorization Request Form

Pharmacy Pre-Authorization:

Other Forms:

Advance Health Care Directives
Disabled Dependent Form
Credentialing Data Form
Recredentialing Verification Form
Supply Reorder Form
W-9 Request

Form

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Directions for Use

Claim Resubmission Request Form

(formerly Adjustment/Corrected Claim Request Form)

Commercial

Medicare VIP

Use this form to provide us with the required information to process your request for an adjusted or corrected claim.

Fill in the appropriate information
Print the form
Mail the completed form to ConnectiCare, Attn: Claim Resubmission, 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

Form

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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.

Form

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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.

Form

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Directions for Use

Provider Appeal Request Form

Commercial

Medicare VIP

If you would like to request reconsideration of a claim that was denied for administrative purposes (e.g., filing limit, coding edits).

Fill in the form online.
Print the completed form.
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.

Form

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Directions for Use

Standard Provider Refund Form

Commercial

Medicare VIP

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

Form

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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.

Form

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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.

Form

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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.

Form

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Directions for Use

Immunization Checklist (Child/Adolescent)

To document information for patient files.

Print the form.
Fill out appropriate information and place in the patient’s file.

Form

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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.

Form

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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.

Form

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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.

Form

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Directions for Use

Vaccine Administration Record (Adult)

To document information for patient files.

Print the form.
Fill out appropriate information and place in the patient’s file.

Form

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Directions for Use

Clinical Review Pre-Authorization Request Form

If you are seeking to obtain authorization of services or procedures included under ConnectiCare’s pre-authorization requirements.

Fill in the form online.
Print the completed form.
Fax the completed form and medical documentation to ConnectiCare’s Clinical Review at 1-800-923-2882 or 860-674-5893. Please use a cover sheet to protect transmission of PHI.
If you have any questions, call Provider Services at 1-800-828-3407.

Form

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Directions for Use

Home Health Care Pre-Authorization Request Form

Commercial

Medicare VIP

If you are seeking to obtain authorization of home health care.

Fill in the form online.
Print the completed form.
Fax the completed form and medical documentation to ConnectiCare’s Clinical Review at 1-866-934-5313 or 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.

Form

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Directions for Use

Infertility Treatment Pre-Authorization Request Form

If you are seeking to obtain authorization for infertility therapy, including infertility prescription drug requests.

Fill in the form online.
Print the completed form.
Fax the completed form and medical documentation to ConnectiCare's Clinical Review at 1-800-923-2882 or 860-674-5893. Please use a cover sheet to protect transmission of PHI.
If you have any questions, call Provider Services at 1-800-828-3407.

Form

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Directions for Use

IV Therapy Authorization Request Form

Commercial

Medicare VIP

If you are seeking to obtain authorization of IV therapy.

Fill in the form online.
Print the completed form.
Fax the completed form and medical documentation to ConnectiCare’s Clinical Review at 1-866-934-5313 or 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.

Form

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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.

Form

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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.

Form

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Directions for Use

Out-of-Network Clinical Review Pre-Authorization Request Form

Commercial

Medicare VIP

If you are seeking to obtain authorization of services or procedures by out-of-network providers.

Fill in the form online.
Print the completed form.
Fax the completed form and medical documentation to ConnectiCare’s Clinical Review at 1-800-923-2882 or 860-674-5893. Please use a cover sheet to protect transmission of PHI.
If you have any questions, call Provider Services at 1-800-828-3407.

Form

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Directions for Use

Outpatient Rehabilitation Therapy Authorization Request Form

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.

Fill in the form online.
Print the completed form.
Attach the complete evaluation for all requested services.
Fax the form and evaluation to 1-860-678-5289 or 1-866-590-3187 (toll free).
If you have any questions, call Provider Services at 1-800-828-3407, Monday through Thursday 8:00 a.m. - 5:00 p.m. and Friday 9:00 a.m. - 5:00 p.m., Eastern time.

Form

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Pharmacy: Non FDA Approved Drug

Use this form when seeking authorization to write a prescription for a drug for off-label use or off-dosage.

Print the form.
Fill in the appropriate information.
Mail the completed form to ConnectiCare, Pharmacy Services, Attn: Clinical Department, 55 Water Street, New York, NY 10041 or, fax to ConnectiCare Clinical Pharmacy Services at 1-877-300-9695.
If you have any questions, call Provider Services at 1-877-224-8230, Monday through Friday 8:00 a.m. - 5:00 p.m., Eastern Time.

Form

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Pharmacy: Addition to Formulary

Use this form to request that a drug be added to the ConnectiCare formulary.

Print the form.
Fill in the appropriate information.
Mail the completed form to ConnectiCare, Pharmacy Services, Attn: Clinical Department, 55 Water Street, New York, NY 10041 or, fax to ConnectiCare Clinical Pharmacy Services at 1-877-300-9695.
If you have any questions, call Provider Services at 1-877-224-8230, Monday through Friday 8:00 a.m. - 5:00 p.m., Eastern Time.

Form

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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.

Form

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Pharmacy Pre-Authorization Form: Anitdepressants

If you are seeking to obtain authorization for antidepressant medications.

Fill in the form online.
Print the completed form.
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.

Form

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Pharmacy Pre-authorization Form: Celebrex

If you are seeking to obtain authorization for Celebrex medication.

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. 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.

Form

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Pharmacy Pre-authorization Form: Cimzia

If you are seeking to obtain authorization for Cimzia.

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.

Form

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Pharmacy Pre-authorization Form: Fibromyalgia and Other Neuropathic Pain

If you are seeking to obtain authorization for Cymbalta or Lyrica for fibromyalgia or other neuropathic pain.

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.

Form

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Pharmacy Pre-authorization Form: Physician Administered Drugs

Commercial

Medicare VIP

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.

Form

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Pharmacy Pre-authorization Form: Proton Pump Inhibitors

If you are seeking to obtain authorization for a Proton Pump Inhibitor.

Fill in the form online.
Print the completed form.
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.

Form

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Pharmacy Pre-authorization Form: Statin Medications

If you are seeking to obtain authorization for 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

Form

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Pharmacy Pre-authorization Form: Testosterone Replacement Therapy

If you are seeking to obtain authorization for testosterone replacement therapy.

Fill in the form online.
Print the completed form.
Fax the completed form to Pharmacy Services (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, Monday through Thursday 8:00 a.m. - 5:30 p.m. and Friday 9:00 a.m. - 5:00 p.m., Eastern Time

Form

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Pharmacy Pre-authorization Form: Hepatitis C

If you are seeking to obtain authorization for interferon treatment of Hepatitis C.

Fill in the form online.
Print the completed form.
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

Form

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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.

Form

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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.

Form

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Credentialing Data Form

If you are looking to submit an application to participate within the ConnectiCare network of participating health care providers.

Fill in the form online.
Print the completed form.
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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Recredentialing Verification Form

If you are looking to submit a recredentialing verification form to continue participating within the ConnectiCare network of participating health care providers and are unable to access CAQH (preferred method).

If you would like to complete a CAQH application, please contact the Credentialing and Vendor Management Department at CCICredentialing@ConnectiCare.com to begin the process.

Fill in the form online.
Print the form.
Fax the completed form to 866-561-9260 or e-mail scanned document with signature to CCICredentialing@ConnectiCare.com or mail to ConnectiCare, Attn: Credentialing and Vendor Management, 175 Scott Swamp Road, Farmington, CT 06032-3124.
If you have any questions, call ConnectiCare’s Credentialing and Vendor Management Department at 866-610-8514.

Form

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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.

Form

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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.

Providers

Headlines

Resources & Tools

Provider Online Forms