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Prescription (Rx) Drugs and Pharmacy Forms

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Appeals and Grievances Forms

Reimbursement Forms

CarePartners of Connecticut HMO Weight Management Reimbursement Form

This form is used to request the $150* Weight Management Reimbursement offered by CarePartners of Connecticut. This benefit will cover up to $150 toward program fees for weight loss programs including Weight Watchers®, Jenny Craig®, or a hospital-based weight loss program. This benefit does not cover costs for pre-packaged meals/foods, books, videos, scales, or other items or supplies.

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Enrollment and Disenrollment Forms

2019 CarePartners of Connecticut Enrollment Form

This form is used to apply for enrollment in a CarePartners of Connecticut HMO plan. Please note, this form is intended for new enrollments. If you are a current member and need to switch your plan, please use the CarePartners of Connecticut HMO plan HMO Short Enrollment Form.

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2019 CarePartners of Connecticut Short Enrollment Form

This form allows current CareParnters of Connecticut members to request enrollment in a different CareParnters of Connecticut plan, in order to switch from one CareParnters of Connecticut plan to another.  Please note, there may be enrollment restrictions depending on when you originally enrolled in your CareParnters of Connecticut coverage.

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2020 CarePartners of Connecticut Enrollment Form

This form is used to apply for enrollment in a CarePartners of Connecticut HMO plan. Please note, this form is intended for new enrollments. If you are a current member and need to switch your plan, please use the CarePartners of Connecticut HMO plan HMO Short Enrollment Form.

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