Get Connecticare Enrollment

This guide provides a clear and supportive overview of how to complete the Connecticare Enrollment form online. Follow these steps to ensure that all information is accurately submitted, facilitating a smooth enrollment process.

Follow the steps to successfully complete the Connecticare Enrollment form

1. Click ‘Get Form’ button to obtain the Connecticare Enrollment form and open it in your preferred editor.
2. Begin by reviewing the sections labeled as Employee and Member(s) to understand the requirements. Ensure you prepare to complete all fields accurately.
3. Indicate whether you are adding or removing a dependent by checking the appropriate boxes. If applicable, specify the reason for enrollment changes.
4. Provide your marital status by selecting the relevant option from the provided choices, ensuring that this information accurately reflects your current situation.
5. Fill in your personal details, including your first name, middle name, last name, and address. Ensure that all entries are clear and legible.
6. List contact information including your work telephone number and home telephone number. Provide your email address for further communication.
7. Input your Social Security Number and date of birth in the required fields, formatted as mm/dd/yy.
8. Select your primary care provider from the available options by entering their details, if already known. Include the Connecticare Provider ID number if available.
9. Answer the questions regarding tobacco usage for yourself and each dependent, ensuring to select yes or no as applicable.
10. Complete the race/ethnicity section if you feel comfortable providing this information. Remember, this section is optional.
11. If you have other health care coverage, indicate yes or no and provide the relevant details, including the policy number and insurance company information.
12. Fill out the employer section accurately, as this information is critical for processing your enrollment. Include your employer's signature.
13. Finally, review all the information entered to confirm its accuracy, then sign and date the form at the designated locations.
14. Once everything is complete, save your changes and choose to download, print, or share the form as needed.

Take the next step and complete your Connecticare Enrollment online today!