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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
Dental Reimbursement Form
Use this form to send a claim for reimbursement of out-of-pocket costs for covered dental services. Y0026_203951_CLast Updated: 11/02/2023
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: 7/06/2021 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_201899_C
Dental Provider Request Form
Use this form if we do not currently have your dentist listed as a participating provider.
Authorization to Use and Disclose Protected Health Information - ConnectiCare
Last Updated: 05/24/2023
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 FormLast updated: 8/27/2019 If you are seeking to obtain authorization of IV therapy.
Medicare Home Health Care Authorization Preauthorization Request FormLast updated: 8/27/2019 If you are seeking to obtain authorization of home health care.
Medicare Out-of-Network Clinical Review Preauthorization Request FormLast updated: 8/27/2019 If you are seeking to obtain authorization of services or procedures by out-of-network providers.
Out-of-Plan Reimbursement FormUse 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_201900_C
Prescription Drug Redetermination Appeals Form
A written request to appeal a drug coverage decision. Y0026_127139_C
Last update 12/01/2023
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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.