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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.

 

Small Group Forms

If your small group plan is administered by one of these distribution partners, visit their websites for forms.

  • ConnectiCare – Fully-Insured Plan Forms

  • CBIA Health Connections – Fully-Insured Plan Forms

  • CBIA Health Connections – Fixed Funding Solutions Plan Forms

  • Access Health CT (SHOP) Plan Forms

 

Large Group Forms

  • 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.

  • Connecticut – Fully Insured Groups

    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.* Change marital status. Change an OB/GYN. Change an address.* Change a primary care physician.* Order a replacement ID Card.*

  • Connecticut – Self-Insured Groups

    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.* Change marital status. Change an OB/GYN. Change an address.* Change a primary care physician.* Order a replacement ID Card.*

  • Massachusetts Groups

    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.* Change marital status. Change an OB/GYN. Change an address.* Change a primary care physician.* Order a replacement ID Card.*

  • Employer Group Size Certification Form

    If you are an employer seeking to determine if your group meets eligibility requirements.

  • Fixed Funding Solutions for Groups with 51-99 Employees

 

Other Forms

  • HSA/HRA Plan Set-Up and Installation Form

    If you are setting up an HSA or HRA plan with the integrated Health Equity solution. This form must accompany the case submission.

  • 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 Reimbursement Claim Form

    If an employee would like to receive reimbursement for prescriptions that were purchased without the use of a ConnectiCare ID Card.

  • 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.

  • Small Group 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.

  • 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 1-800-251-7722.

  • 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.

  • Premium Credit for Terminated Employees Form

    If you are an employer with a Connecticut insured plan and you want to elect not to pay the group health insurance premium for employees and dependents under certain conditions. These conditions are: Employee voluntarily terminates; or Employer terminates an employee for reasons other than layoff. The employee is not subject to a collective bargaining agreement requiring that you pay the premium.

  • Small Group Size Certification Form

    If you are an employer seeking to determine if your group meets eligibility requirements.
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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.