Health Delivery Organization (HDO) Form

Updated 04/2025

All ancillary applicants requesting to participate within the ConnectiCare network of participating health care providers.

Provider Credentialing Form

Apply to be part of the ConnectiCare network of participating health care providers or update your demographic information.

Claim Resubmission Request Form

Provide the required information to process your request for an adjusted or corrected claim.

Claim Status Request Form

Request claim status.

Electronic Funds Transfer Authorization

Request payment directly into your bank account on the same day we issue a reimbursement check.

Clinical Review Preauthorization Request Form

Request authorization of services or procedures included under ConnectiCare’s preauthorization requirements.

Infertility Treatment Form

Information needed for preauthorization request for infertility therapy, including infertility prescription drugs.

Out-of-Network Clinical Review Preauthorization Request Form

Request authorization of services or procedures by out-of-network providers. 

Cardiac Imaging Preauthorization Form

Request preauthorization for Myocardial Perfusion Imaging (MPI), Stress Echocardiogram or Multiple Gated Acquisition Scan (MUGA) services.

PET CT Preauthorization Form

Request preauthorization for PET or PET CT imaging services.

CT/CTA/MRI/MRA Preauthorization Form

Request preauthorization for CT, CTA, MRI, or MRA imaging services.

Pharmacy Preauthorization Form: General Requests

Pharmacy Preauthorization Form: Massachusetts Preauthorization Requests Form

Provider Checklist: Items Needed to Process Appeals

Advance Health Care Directives

Provide your patients with information on how to create an advance directive. 

Disabled Dependent Form

Request continuation of ConnectiCare health care coverage on behalf of a disabled ConnectiCare dependent who has reached the maximum dependent age limit.