Member information update form
Update a Social Security number for you or a dependent for IRS Form 1095-B.
Fill out to make many changes such as adding a dependent, electing COBRA, name or marital status change. Want to do it faster? You can make some changes on our secure member website. Sign in.
Disabled dependent form
Request continued ConnectiCare health care coverage for a disabled dependent who has reached the maximum dependent age limit.
Prescription drug reimbursement claim form
Request reimbursement for prescriptions purchased without your ConnectiCare identification (ID) card.
Out-of-plan reimbursement form
Request reimbursement for a medical service you paid for or you received from an out-of-network provider; request coordination of benefits with you primary insurance company.
Infertility treatment and procedures disclosure form
Request health insurance coverage for infertility treatment or procedures.
COBRA election notice form
Complete to choose COBRA coverage through a former employer.
Claim pre-estimate form
Fill out to see how much a service or treatment will cost you.
Request for personal information
Ask for information ConnectiCare has on file about you: medical and pharmacy claims history, authorizations, and premium billing.
HIPAA privacy release form
Written authorization required for ConnectiCare to release a member's personal health information to someone else.