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Member Forms

All forms are in PDF format using Adobe Reader. All forms are the exclusive property of ConnectiCare, or used by ConnectiCare with permission, and protected by copyright. 


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. 


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. 


Coverage Determination Form 
Solicitud de determinacion de cobertura de medicamentos de receta de Medicare 
Y0026_128075_C
Use this form when requesting coverage tiering exceptions or coverage for a drug that is not listed on the plan's list of covered drugs.


Prescription drug redetermination appeals form 
Solicitud de Redeterminación de Denegación de Medicamento de Receta de Medicare 
Y0026_127860_C_NM
A written request to appeal a drug coverage decision.


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


Prescription Direct Reimbursement Form 
Servicios de farmacia formulario de reclamacion de medicamentos de receta 
Y0026_126502_C NM
Last updated: 4/17/2019
Use this form to request reimbursement of drugs for which the member paid for out-of-pocket at the pharmacy.


Vision and Hearing Aid Allowance Reimbursement Form 
H3528_C1967_C
For Passage Plan 1 (HMO) members only. Use this form to file a claim for reimbursement of eyeglass frames, lenses, contact lenses or hearing aids.


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


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.


Clinical Review Pre-Authorization Request Form
Last updated: 8/27/2019
If you are seeking to obtain authorization of services or procedures included under ConnectiCare's pre-authoriztion requirements.


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 Pre-Authorization Request Form

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


Medicare Out-of-Network Clinical Review Pre-Authorization Request Form

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




Y0026_200218_C
Last Update 10/1/2019

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