Forms and Documents

If you need a copy of a particular form, ConnectiCare's online form resource can save you time. 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.

Application Forms

Health Delivery Organization (HDO) Form
Updated 04/2025

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

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Provider Network Management Portal
Apply to be a part of the ConnectiCare network of participating health providers or add practitioners to your group.
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Claims Payment

Claim Resubmission Request Form
Provide the required information to process your request for an adjusted or corrected claim.
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Claim Status Request Form
Request claim status.
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Electronic Funds Transfer Authorization
Request payment directly into your bank account on the same day we issue a reimbursement check.
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Medical Preauthorization

Clinical Review Preauthorization Request Form
Request authorization of services or procedures included under ConnectiCare’s preauthorization requirements.
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Infertility Treatment Form
Information needed for preauthorization request for infertility therapy, including infertility prescription drugs.
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Out-of-Network Clinical Review Preauthorization Request Form
Request authorization of services or procedures by out-of-network providers.
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For Massachusetts Providers Only

Cardiac Imaging Preauthorization Form
Request preauthorization for Myocardial Perfusion Imaging (MPI), Stress Echocardiogram or Multiple Gated Acquisition Scan (MUGA) services.
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PET CT Preauthorization Form
Request preauthorization for PET or PET CT imaging services.
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CT/CTA/MRI/MRA Preauthorization Form
Request preauthorization for CT, CTA, MRI, or MRA imaging services.
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Pharmacy Preauthorization

Pharmacy Preauthorization Form: General Requests
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Pharmacy Preauthorization Form: Massachusetts Preauthorization Requests Form
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Other Forms

Provider Checklist: Items Needed to Process Appeals
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Advance Health Care Directives
Provide your patients with information on how to create an advance directive.
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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.
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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.