Plan forms for Members

Switch to:

Forms

Find benefit summaries, lists of covered drugs(formularies), and all necessary forms to get the most out of your ConnectiCare coverage.

Looking for Medicare forms and documents?

 

Looking for Access Health CT plan documents?

Looking for SOLO plan documents?


  • Member information update form

    Update a Social Security number for you or a dependent for  IRS Form 1095-B.

  • Enrollment/Change form

    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.