Get State Of Connecticut Emergency Room Copayment Waiver - Osc Ct

The State of Connecticut Emergency Room Copayment Waiver is essential for employees seeking to waive the $35 copayment for emergency room visits. This guide provides clear and detailed steps to assist users in filling out the form accurately online.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the Emergency Room Copayment Waiver form and open it in your editor.
2. Provide your personal information in the designated fields. Enter your last name, first name, middle initial, employee number, and medical ID number as requested.
3. Fill in your residential address, including street address, city, state, and zip code. Make sure to include a personal email address and your home or cell phone number. Do not use work contact information.
4. Enter the patient’s details. Include the patient’s name, medical ID number, relationship to the subscriber, date of birth, place of treatment, date of treatment, and the time of treatment. Ensure the time of treatment is specified with a.m. or p.m.
5. Indicate the condition for which emergency treatment was sought in the field provided.
6. Check all applicable circumstances that justify the waiver request, such as seeking advice from the 24-hour nurse line, primary care physician, or any other relevant situation that validates your visit to the emergency room.
7. Review all entered information for accuracy. Inaccurate or missing details may delay the processing of your waiver request.
8. By signing the form, you certify that all provided information is true. Include your signature and the date of signing.
9. Submit the completed form to the appropriate carrier, either by mail or fax, as specified in the instructions.

Ensure your emergency room copayment is waived by completing your form online today.