Forms
HMO Forms
Prescription (Rx) Drugs and Pharmacy Forms
CarePartners of Connecticut Personal Medication List
Complete this form to help organize and track your medications. Keeping it up to date will ensure you have a list of your current medications which can be shared with doctors, caregivers and loved ones as needed.
View Form called CarePartners of Connecticut Personal Medication ListCarePartners of Connecticut Request for Medicare Prescription Drug Coverage Determination
This form is used to submit a request for coverage, or payment, of a prescription drug through a CarePartners of Connecticut HMO or PPO plan.
View Form called CarePartners of Connecticut Request for Medicare Prescription Drug Coverage DeterminationCoverage Determination and Prior Authorization Request for Medicare Part B versus Part D
This form allows physicians to submit information to CarePartners of Connecticut to help determine drug coverage for CarePartners of Connecticut and proper payment under Medicare Part B versus Part D per the Centers for Medicare and Medicaid Services(CMS).
View Form called Coverage Determination and Prior Authorization Request for Medicare Part B versus Part DCVS Caremark Mail Order Form
View Form called CVS Caremark Mail Order FormCVS Caremark Medicare Part D Prescription Claim Form
This form allows you to file a Medicare Part D claim through CVS Caremark.
View Form called CVS Caremark Medicare Part D Prescription Claim FormHepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
View Form called Hepatitis C Medication Request FormMTM Blank Medication List
This form is used to document medications as part of the MTM programming.
View Form called MTM Blank Medication ListPart D Late Enrollment Penalty (LEP) Reconsideration Request Form
This form is used to submit a request for reconsideration to eliminate your Part D late enrollment penalty.
View Form called Part D Late Enrollment Penalty (LEP) Reconsideration Request FormAuthorization and Appointment of Representative Forms
Authorization to Disclose Protected Health Information
This form allows you to authorize CarePartners of Connecticut to disclose your protected health information to a person or entity. This form should be used for member enrolled in a CarePartners of Connecticut plan.
View Form called Authorization to Disclose Protected Health InformationCenters for Medicare & Medicaid Services Appointment of Representative Form
This form is used by Medicare/Medicaid members to appoint a representative to act on their behalf in filing a grievance, requesting an initial determination, or in dealing with any of the levels of the appeal.
View Form called Centers for Medicare & Medicaid Services Appointment of Representative FormDesignated Representative Form
This form is used to designate a representative to act on a member’s behalf and authorize CarePartners of Connecticut to disclose the member’s protected health information to the representative.
View Form called Designated Representative FormPersonal Representative Cover Form
This form is used as a cover sheet to submit with your legal personal representative documents.
View Form called Personal Representative Cover FormTermination of Authorization or Restriction
This form allows member to terminate an existing authorization or restriction.
View Form called Termination of Authorization or RestrictionFinancial and Payment Forms
CarePartners of Connecticut Electronic Funds Transfer (EFT) Authorization Form
This form allows you to sign up for Electronic Funds Transfer (EFT) payments. When you sign up for EFT payments, your CarePartners of Connecticut Plan premium payment is automatically deducted from your checking or savings account each month.
View Form called CarePartners of Connecticut Electronic Funds Transfer (EFT) Authorization FormAppeals and Grievances Forms
CarePartners of Connecticut Request for Redetermination of Medicare Prescription Drug Denial (HMO)
This form is used to submit a redetermination (appeal) of a previously declined request for coverage or payment of a prescription drug through a CarePartners of Connecticut HMO plan. Please note that you have 60 days from the date of the initial Notice of Denial of Medicare Prescription Drug Coverage to request a redetermination.
View Form called CarePartners of Connecticut Request for Redetermination of Medicare Prescription Drug Denial (HMO)Reimbursement Forms
2022 Annual Wellness Visit Healthy Reward Program Form
CarePartners of Connecticut HMO and PPO members can earn a $50 reward for completing an Annual Wellness Visit with your provider between January 1, 2022 and December 15, 2022. Upon completion of your Annual Wellness Visit, fill out the Healthy Reward Form and return it postmarked by 12/15/2022 to receive your gift card within 4-6 weeks
View Form called 2022 Annual Wellness Visit Healthy Reward Program Form2022 CarePartners of Connecticut CareAdvantage Preferred (HMO) Wellness Allowance Reimbursement Form
Use this form to request the Wellness Allowance Reimbursement. This benefit applies to the CarePartners of Connecticut CareAdvantage Preferred (HMO) plan only.
View Form called 2022 CarePartners of Connecticut CareAdvantage Preferred (HMO) Wellness Allowance Reimbursement Form2022 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.
View Form called 2022 CarePartners of Connecticut HMO Weight Management Reimbursement Form2022 CarePartners of Connecticut Member Reimbursement Form
This form allows CarePartners of Connecticut plan members to request reimbursement for any health care services you have received that were not initially covered by CarePartners of Connecticut (including out-of-country health care services).
View Form called 2022 CarePartners of Connecticut Member Reimbursement FormCarePartners of Connecticut HMO and PPO Member Dental Claim Form
This form is used to request reimbursement for covered in- or out-of-network dental services that were not originally covered by CarePartners of Connecticut at point of service.
View Form called CarePartners of Connecticut HMO and PPO Member Dental Claim FormCarePartners of Connecticut Out-of-Network Vision Services Claim Form
This form is used if you are visiting a provider that is not a participating provider in the EyeMed Network. Not all plans have out-of-network benefits, so please consult your CarePartners of Connecticut Evidence of Coverage to ensure coverage of services.
View Form called CarePartners of Connecticut Out-of-Network Vision Services Claim FormCOVID-19 Testing Reimbursement Form
This form can be mailed to CarePartners of Connecticut for COVID-19 at-home test reimbursement. A copy of receipt will be required for reimbursement. The form includes further instructions on how to submit for reimbursement.
View Form called COVID-19 Testing Reimbursement FormEnrollment and Disenrollment Forms
2022 CarePartners Dental Enrollment Form
This form is used to apply for enrollment in a CarePartners of Connecticut dental plan.
View Form called 2022 CarePartners Dental Enrollment Form2022 CarePartners of Connecticut Enrollment Form (HMO)
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.
View Form called 2022 CarePartners of Connecticut Enrollment Form (HMO)2022 CarePartners of Connecticut Pre-Enrollment Checklist (HMO)
This form helps you better understand the enrollment process, plan benefits and rules prior to enrolling.
View Form called 2022 CarePartners of Connecticut Pre-Enrollment Checklist (HMO)2023 CarePartners Dental Enrollment Form
This form is used to apply for enrollment in a CarePartners of Connecticut dental plan. Last Updated 10/01/2022.
View Form called 2023 CarePartners Dental Enrollment Form2023 CarePartners of Connecticut HMO Short Enrollment Form
This form allows current CarePartners of Connecticut members to request enrollment in a different CarePartners of Connecticut plan, in order to switch from one CarePartners of Connecticut plan to another, or add the Dental Option to a current CarePartners of Connecticut plan. Please note, there may be enrollment restrictions depending on when you originally enrolled in your CarePartners of Connecticut plan coverage. Last Updated 10/01/2022.
View Form called 2023 CarePartners of Connecticut HMO Short Enrollment Form2023 CarePartners of Connecticut Individual Enrollment Form
This form is used to apply for enrollment in a CarePartners of Connecticut 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 plan Short Enrollment Form. Last Updated 10/01/2022.
View Form called 2023 CarePartners of Connecticut Individual Enrollment Form2023 CarePartners of Connecticut Pre-Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and rules prior to enrolling. Last Updated 10/01/2022.
View Form called 2023 CarePartners of Connecticut Pre-Enrollment ChecklistCarePartners of Connecticut HMO Disenrollment Form
This form is used to disenroll from CarePartners of Connecticut Medicare HMO plans. Please note that you must continue to get all medical care from CarePartners of Connecticut until the effective date of disenrollment.
View Form called CarePartners of Connecticut HMO Disenrollment FormRequest for Protected Health Information
Member Request for Protected Health Information
This form is for use by members to request their own protected health information.
View Form called Member Request for Protected Health InformationPPO Forms
Prescription (Rx) Drugs and Pharmacy Forms
CarePartners of Connecticut Personal Medication List
Complete this form to help organize and track your medications. Keeping it up to date will ensure you have a list of your current medications which can be shared with doctors, caregivers and loved ones as needed.
View Form called CarePartners of Connecticut Personal Medication ListCarePartners of Connecticut Request for Medicare Prescription Drug Coverage Determination
This form is used to submit a request for coverage, or payment, of a prescription drug through a CarePartners of Connecticut HMO or PPO plan.
View Form called CarePartners of Connecticut Request for Medicare Prescription Drug Coverage DeterminationCoverage Determination and Prior Authorization Request for Medicare Part B versus Part D
This form allows physicians to submit information to CarePartners of Connecticut to help determine drug coverage for CarePartners of Connecticut and proper payment under Medicare Part B versus Part D per the Centers for Medicare and Medicaid Services(CMS).
View Form called Coverage Determination and Prior Authorization Request for Medicare Part B versus Part DCVS Caremark Mail Order Form
View Form called CVS Caremark Mail Order FormCVS Caremark Medicare Part D Prescription Claim Form
This form allows you to file a Medicare Part D claim through CVS Caremark.
View Form called CVS Caremark Medicare Part D Prescription Claim FormHepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
View Form called Hepatitis C Medication Request FormMTM Blank Medication List
This form is used to document medications as part of the MTM programming.
View Form called MTM Blank Medication ListPart D Late Enrollment Penalty (LEP) Reconsideration Request Form
This form is used to submit a request for reconsideration to eliminate your Part D late enrollment penalty.
View Form called Part D Late Enrollment Penalty (LEP) Reconsideration Request FormAuthorization and Appointment of Representative Forms
Authorization to Disclose Protected Health Information
This form allows you to authorize CarePartners of Connecticut to disclose your protected health information to a person or entity. This form should be used for member enrolled in a CarePartners of Connecticut plan.
View Form called Authorization to Disclose Protected Health InformationCenters for Medicare & Medicaid Services Appointment of Representative Form
This form is used by Medicare/Medicaid members to appoint a representative to act on their behalf in filing a grievance, requesting an initial determination, or in dealing with any of the levels of the appeal.
View Form called Centers for Medicare & Medicaid Services Appointment of Representative FormDesignated Representative Form
This form is used to designate a representative to act on a member’s behalf and authorize CarePartners of Connecticut to disclose the member’s protected health information to the representative.
View Form called Designated Representative FormPersonal Representative Cover Form
This form is used as a cover sheet to submit with your legal personal representative documents.
View Form called Personal Representative Cover FormTermination of Authorization or Restriction
This form allows member to terminate an existing authorization or restriction.
View Form called Termination of Authorization or RestrictionFinancial and Payment Forms
CarePartners of Connecticut Electronic Funds Transfer (EFT) Authorization Form
This form allows you to sign up for Electronic Funds Transfer (EFT) payments. When you sign up for EFT payments, your CarePartners of Connecticut Plan premium payment is automatically deducted from your checking or savings account each month.
View Form called CarePartners of Connecticut Electronic Funds Transfer (EFT) Authorization FormAppeals and Grievances Forms
CarePartners of Connecticut Request for Redetermination of Medicare Prescription Drug Denial (PPO)
This form is used to submit a redetermination (appeal) of a previously declined request for coverage or payment of a prescription drug through a CarePartners of Connecticut PPO plan. Please note that you have 60 days from the date of the initial Notice of Denial of Medicare Prescription Drug Coverage to request a redetermination.
View Form called CarePartners of Connecticut Request for Redetermination of Medicare Prescription Drug Denial (PPO)Reimbursement Forms
CarePartners of Connecticut HMO and PPO Member Dental Claim Form
This form is used to request reimbursement for covered in- or out-of-network dental services that were not originally covered by CarePartners of Connecticut at point of service.
View Form called CarePartners of Connecticut HMO and PPO Member Dental Claim FormCarePartners of Connecticut Out-of-Network Vision Services Claim Form
This form is used if you are visiting a provider that is not a participating provider in the EyeMed Network. Not all plans have out-of-network benefits, so please consult your CarePartners of Connecticut Evidence of Coverage to ensure coverage of services.
View Form called CarePartners of Connecticut Out-of-Network Vision Services Claim FormCOVID-19 Testing Reimbursement Form
This form can be mailed to CarePartners of Connecticut for COVID-19 at-home test reimbursement. A copy of receipt will be required for reimbursement. The form includes further instructions on how to submit for reimbursement.
View Form called COVID-19 Testing Reimbursement FormEnrollment and Disenrollment Forms
2022 CarePartners Dental Enrollment Form
This form is used to apply for enrollment in a CarePartners of Connecticut dental plan.
View Form called 2022 CarePartners Dental Enrollment Form2022 CarePartners of Connecticut PPO Enrollment Form
This form is used to apply for enrollment in a CarePartners of Connecticut PPO 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 PPO plan PPO Short Enrollment Form.
View Form called 2022 CarePartners of Connecticut PPO Enrollment Form2022 CarePartners of Connecticut Pre-Enrollment Checklist (PPO)
This form helps you better understand the enrollment process, plan benefits and rules prior to enrolling.
View Form called 2022 CarePartners of Connecticut Pre-Enrollment Checklist (PPO)2023 CarePartners of Connecticut Individual Enrollment Form
This form is used to apply for enrollment in a CarePartners of Connecticut 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 plan Short Enrollment Form. Last Updated 10/01/2022.
View Form called 2023 CarePartners of Connecticut Individual Enrollment Form2023 CarePartners of Connecticut Pre-Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and rules prior to enrolling. Last Updated 10/01/2022.
View Form called 2023 CarePartners of Connecticut Pre-Enrollment ChecklistCarePartners of Connecticut PPO Disenrollment Form
This form is used to disenroll from CarePartners of Connecticut Medicare PPO plans. Please note that you must continue to get all medical care from CarePartners of Connecticut until the effective date of disenrollment.
View Form called CarePartners of Connecticut PPO Disenrollment FormRequest for Protected Health Information
Member Request for Protected Health Information
This form is for use by members to request their own protected health information.
View Form called Member Request for Protected Health Information