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Employer Forms

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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.

  • HIPAA Authorization Form

    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 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 800-251-7722.
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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary,or other plan documents for specific information about your benefits coverage.