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Member Services

Member Forms

If you need a copy of a particular form, ConnectiCare's Online Form Resource can save you time. Click here to access Online Forms. 

Medicare Fraud and Protection

Click here for tips on what you can do to prevent fraudulent schemes and help protect your identity and benefits. 

Coverage Decisions

Click here for information on how to request a coverage decision (the process to determine if an item or medical service is covered).


Click here for information on how to file an appeal (a formal way of asking us to review and change a coverage decision we made).


Click here for information to submit a grievance (a formal name for making a complaint).

Appoint a Representative

If you want someone to act on your behalf then you and that person must sign a statement that gives that person legal permission to act as your appointed representative. Click here for more details on how to appoint a representative.

Potential Reasons for Plan/Policy Termination

You have some responsibilities as a member of ConnectiCare. Click here for details on how to avoid membership termination from the Plan.

H3528_18_4006_01r11 Approved 05/09/2018
Last Update 04/19/2018