Forms

Individuals and Families

Health & Wellness

• 2017 CareConnect Wellness Flyer
• Care Away From Home

Prescription Drug Information

• Formulary (Prescription Drug Information) as of 09/01/2018
• Formulary (Prescription Drug Information) as of 10/01/2018
• Formulary (Prescription Drug Information) as of 08/01/2018
• CVS Mail Service Order Form
• CVS Claim Form
• 2017 CareConnect Specialty Medications
• CVS/Caremark Maintenance Drugs

Claims

• Health Insurance Claim Form
• Appeals and Grievances Request Form

Other

• 2017 – 2018 Provider Directory
• Disability Status Request Form

Brokers

Applications

• 2017 Small Group Member Application
• 2016 Large Group Member Application

Enrollment

• Add/Change/Delete Form
• New Business Submission Checklist
• Group Attestation
• Waiver of Coverage

Groups and Employers

• Add/Change/Delete Form
• New Business Submission Checklist
• Waiver of Coverage Form

Providers

• Quick Reference Guide
• Provider Information Change Form
• Preauthorization Requirements
• Provider Manual
• Court Ordered Substance Abuse Mandate
• Inpatient Substance Abuse Request Appendix A

Legal and Privacy

• Video Testimonial Release Consent
• Testimonial Release Consent
• Request for Access to Health Information
• Authorization for Disclosure of Health Information
• Request for Confidential Communication by Alternative Means
• Request to Amend Protected Health Information
• New York State Surprise Medical Bill Assignment of Benefits Form
• Request for an Accounting of Disclosures
• Revocation-of-Restrictions-Of-Use-Disclosure-of-PHI-Form.pdf
• Request-Restrictions-of-Use-Disclosure-Form.pdf
• Revocation-of-Confidential-Communications-by-Alternative-Means.pdf