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?
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.
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.
Authorization to Use and Disclose Protected Health Information - ConnectiCare
Authorization, Verification and Certification Forms Authorization to Use and Disclose Protected Health Information. A written authorization is required for your plan to share a member's protected health information with anyone, except as required or permitted by law.
