Forms
HMO Forms
Prescription (Rx) Drugs and Pharmacy Forms
2023 Hepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
View Form called 2023 Hepatitis C Medication Request Form2023 OptumRx Home Delivery Prescription Order Form
This form allows CarePartners of Connecticut Medicare Advantage HMO and PPO plan members to request home delivery of prescription drugs through the OptumRx mail order service. Last Updated 12/08/2022.
View Form called 2023 OptumRx Home Delivery Prescription Order FormCarePartners 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 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 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 FormFinancial 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 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. This form is for purchases made in 2022 and must be received by CarePartners of Connecticut by March 31, 2023.
View Form called 2022 CarePartners of Connecticut CareAdvantage Preferred (HMO) Wellness Allowance 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). This form is for purchases made in 2022 and must be received by CarePartners of Connecticut by March 31, 2023.
View Form called 2022 CarePartners of Connecticut Member Reimbursement Form
2022 CarePartners of Connecticut 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. This form is for purchases made in 2022 and must be received by CarePartners of Connecticut by March 31, 2023.
View Form called 2022 CarePartners of Connecticut Weight Management Reimbursement Form2022 COVID-19 Testing Reimbursement Form
This form can be mailed to CarePartners of Connecticut for COVID-19 at-home test purchases made from February 1, 2022, through December 31, 2022. A copy of receipt will be required for reimbursement. This form is for purchases made in 2022 and must be received by CarePartners of Connecticut by March 31, 2023.
View Form called 2022 COVID-19 Testing Reimbursement Form2023 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. Last Updated 01/06/2023.
View Form called 2023 CarePartners of Connecticut CareAdvantage Preferred (HMO) Wellness Allowance Reimbursement Form2023 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). Last Updated 01/06/2023.
View Form called 2023 CarePartners of Connecticut Member Reimbursement Form2023 CarePartners of Connecticut Weight Management Reimbursement Form
This form is used to request the Weight Management Reimbursement offered by CarePartners of Connecticut. Last Updated 01/06/2023.
View Form called 2023 CarePartners of Connecticut Weight Management Reimbursement Form2023 Optum Medicare Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by CarePartners of Connecticut. Last Updated 12/08/2022.
View Form called 2023 Optum Medicare Part D Prescription 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 FormEnrollment and Disenrollment Forms
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
2023 Hepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
View Form called 2023 Hepatitis C Medication Request Form2023 OptumRx Home Delivery Prescription Order Form
This form allows CarePartners of Connecticut Medicare Advantage HMO and PPO plan members to request home delivery of prescription drugs through the OptumRx mail order service. Last Updated 12/08/2022.
View Form called 2023 OptumRx Home Delivery Prescription Order FormCarePartners 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 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 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 FormFinancial 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
2022 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). This form is for purchases made in 2022 and must be received by CarePartners of Connecticut by March 31, 2023.
View Form called 2022 CarePartners of Connecticut Member Reimbursement Form
2022 CarePartners of Connecticut 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. This form is for purchases made in 2022 and must be received by CarePartners of Connecticut by March 31, 2023.
View Form called 2022 CarePartners of Connecticut Weight Management Reimbursement Form2022 COVID-19 Testing Reimbursement Form
This form can be mailed to CarePartners of Connecticut for COVID-19 at-home test purchases made from February 1, 2022, through December 31, 2022. A copy of receipt will be required for reimbursement. This form is for purchases made in 2022 and must be received by CarePartners of Connecticut by March 31, 2023.
View Form called 2022 COVID-19 Testing Reimbursement Form2023 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). Last Updated 01/06/2023.
View Form called 2023 CarePartners of Connecticut Member Reimbursement Form2023 CarePartners of Connecticut Weight Management Reimbursement Form
This form is used to request the Weight Management Reimbursement offered by CarePartners of Connecticut. Last Updated 01/06/2023.
View Form called 2023 CarePartners of Connecticut Weight Management Reimbursement Form2023 Optum Medicare Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by CarePartners of Connecticut. Last Updated 12/08/2022.
View Form called 2023 Optum Medicare Part D Prescription 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 FormEnrollment and Disenrollment Forms
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