Employer Forms
Taking Care of Business
Find forms that are sometimes needed for you or your employees.
Taking Care of Business
Find forms that are sometimes needed for you or your employees.
Forms
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.Prescription Drug Mail Pharmacy Order Form
If an employee would like to receive a 90-day supply of maintenance prescription drugs through the mail.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.
