ConnectiCare Forms - Connecticut small group (1-50)
To respect the privacy of our
members, if you download and print enrollment forms that include a
medical questionnaire, you should suggest a mechanism for
transmitting the completed form. That mechanism should be one
that will protect the confidentiality of the person's health
information, such as taping or stapling the forms closed, sealing
them in an envelope, and mailing or faxing them to an Aetna address
or fax number that you provide.
FORM |
|
PURPOSE |
| Small Group Renewal Certification Form (CT) |
Download |
To insure continuation of your Small Group coverage with ConnectiCare |
| Small Group Proposal Request (CT) |
Download |
If you are an agent/broker for a small employer group and you are seeking to obtain a quote. |
| Small Group Employer Application |
Download |
If you are an agent/broker for a small employer group and you are seeking to enroll a new ConnectiCare group. |
| New Business Certification Statement |
Download |
Used with a small employer group that has been in business for at least 3 consecutive months, but has not yet filed a quarterly wage and tax statement (UC2 or UC5a), |
| Enrollment/Change Form |
Download |
Used to enroll or make changes in membership including: changes in providers, addresses, plan choice, name, marital status, etc. |
| CT Family Health Statement Form |
Download |
If you are an employee of a Connecticut small employer group (Employer with less than 50 full-time employees). |
| Waiver Form |
Download |
When an eligible employee is declining coverage through ConnectiCare, based on one of the reasons on the form (Can be used instead of completing the middle section of the Family Health Statement to decline coverage.) |
| Authorization Form |
Download |
If you are assisting a member with resolution of a claims or health benefit coverage issue and seeking disclosure of the member's protected health information as part of this process. |
| Eligibility Form |
Download |
If you are an agent/broker for a small employer group and you are seeking to enroll a husband/wife business filing a Schedule C form and spouse does not appear on the Schedule C form. |
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