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Forms

Prescription (Rx) Drugs and Pharmacy Forms

Authorization and Appointment of Representative Forms

Financial and Payment Forms

Appeals and Grievances Forms

Reimbursement Forms

2020 Healthy Behavior Reward

This form allows CarePartners of Connecticut plan members to earn the Healthy Behavior Reward for the contract year 2020. Simply complete this form showing proof of your healthy behavior related to diabetes care. Then mail or fax it to CarePartners of Connecticut by 11/30/2020. 

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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

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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