ConnectiCare Massachusetts Forms

For Employers

• Employer Application
  (for groups effective January 2023 and beyond)
• Employer Application
  (for groups effective January 2022 through December 2022)
• Rules and Requirements
• Group Size Certification
• Small Group Information Change
• Massachusetts Non-Discrimination Certification Form
• Direct Debit Form
• Binder Payment Form
• Registration for Online Account Access

For Employees

• Enrollment/Change Form
  (for groups effective January 2023 and beyond)
• Enrollment/Change Form
  (for groups effective January 2022 through December 2022)
• 2023 Individual Enrollment Form
• 2022 Individual Enrollment Form
• Waiver of Coverage Form
• Domestic Partner Affidavit
• Application for Continuation of Coverage for a Disabled Dependent Child
• Authorization to Use or Disclose Protected Health Information (HIPAA Release Form)
• Language and Non-Discrimination Notice