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Medicare Advantage plan documents


Forms

Find forms for reimbursement, coverage determination, and more.

  • Vision, hearing aid allowance and/or over the counter (OTC) reimbursement form

    Use this form to file a claim for reimbursement of out of pocket costs of covered eyewear, hearing aids and/or OTC plan benefits (if applicable). Do not use this form for post-cataract eyewear reimbursement requests. Y0026_200572-C

  • Authorization of representative (AOR)

    An enrollee may appoint any individual to act as his or her representative. To be appointed by an enrollee, both the enrollee making the appointment and the representative accepting the appointment must sign, date, and complete an authorization form.

  • Clinical review preauthorization request form

    Last updated: 8/27/2019 If you are seeking to obtain authorization of services or procedures included under ConnectiCare's preauthorization requirements.

  • Coverage determination form

    An exception is a type of coverage determination. You may ask for an exception if you need a drug that is not on our list of covered drugs. You may also ask for an exception to rules, such as a limit on the quantity of a drug.  Y0026_128075_C

  • Dental provider request form

    Use this form if we do not currently have your dentist listed as a participating provider. Y0026_c1985_C

  • HIPAA privacy release form

    If you would like someone other than yourself to have access to your medical records, this written authorization is required for ConnectiCare to release a member's personal health information.

  • Medicare IV therapy authorization request form

    Last updated: 8/27/2019 If you are seeking to obtain authorization of IV therapy.

  • Medicare home health care authorization preauthorization request form

    Last updated: 8/27/2019 If you are seeking to obtain authorization of home health care.

  • Medicare out-of-network clinical review preauthorization request form

    Last updated: 8/27/2019 If you are seeking to obtain authorization of services or procedures by out-of-network providers.

  • Out-of-plan reimbursement form

    Use this form when requesting reimbursement for a covered medical service that you paid out of your own pocket. Y0026_C19148_C

  • Prescription direct reimbursement form

    Use this form to request reimbursement of drugs for which the member paid for out-of-pocket at the pharmacy. Y0026_126502_C NM

  • Prescription drug redetermination appeals form

    A written request to appeal a drug coverage decision. Y0026_127860_C_NM

  • Request for accounting of disclosures

    A written request for ConnectiCare to share with the member any personal health information that ConnectiCare has shared for reasons other than to facilitate treatment, pay claims, or health plan operations.

  • Request for confidential communication

    Last updated: 8/27/2019 A written request for special handling of personal health information.

  • Request for personal information

    Last updated: 8/27/2019 A written request to obtain personal health information that ConnectiCare has on file about the member.

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Medicare members call 1-800-224-2273 (TTY: 711)
If not currently enrolled call 1-877-224-8221

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Last update 12/01/2020

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