Get Ct Connecticare Out-of-plan Reimbursement Form 2019-2025

This guide provides clear, step-by-step instructions for filling out the CT ConnectiCare Out-of-Plan Reimbursement Form online. Whether you are seeking reimbursement for medical expenses or requiring payment to an out-of-plan provider, this guide will help you complete the form accurately and efficiently.

Follow the steps to complete the form effectively.

1. Click the ‘Get Form’ button to obtain the CT ConnectiCare Out-of-Plan Reimbursement Form and open it in your preferred editor.
2. Fill out the member's name at the top of the form, including the last name, first name, and middle name initial.
3. Enter your member ID number as indicated on your ID card.
4. Provide your full address, including street number and name, city, state, and ZIP code.
5. Include your telephone number in the designated space; ensure the format is correct.
6. Indicate your birthdate using the specified format and select your gender by checking the appropriate box.
7. Answer the question regarding whether your condition is related to an accident or illness by selecting the appropriate options.
8. If you are covered under another health benefit plan, answer 'Yes' or 'No.' If 'Yes,' proceed to provide the other insured's information as requested.
9. Detail all required information regarding the other insurance plan, including the insured's name, policy numbers, date of birth, and insurance plan name.
10. Specify whether the payment should be made to yourself or your provider and confirm it by checking the correct box.
11. If payment should go to your provider, you must sign in the designated section to authorize this payment.
12. Sign again in the section that allows for the release of information necessary to process your claim.
13. Fill in any additional comments or information in the provided section.
14. Once all sections are completed, save your changes and consider downloading or printing a copy for your records before submission.

Complete your forms online for a hassle-free reimbursement process.