Member Forms

Enrollment / Disenrollment

2024 Enrollment Form. Use this form to enroll in Trinity Health Plan Of Connecticut.
Dental Disenrollment Form. Use this form to disenroll from your optional supplemental dental plan. Note: You may disenroll from a supplemental dental plan without ending your membership in Trinity Health Plan Of Connecticut.
Disenrollment Form. Use this form to disenroll from Trinity Health Plan Of Connecticut.

Release of Information Form. Use this form to allow loved ones to access your protected health information.
CMS Appointment of Representative Form. Use this form to appoint someone to represent you on formal matters, such as appeals or grievances.
Connecticut Advanced Directive. Use this form to authorize someone to act on your behalf for private, health-related decisions or legal matters.
VA Release of Information Form. Use this form to authorize the Department of Veterans Affairs to release health-related information to those you designate.

CVS Caremark Prescription Mail Order Form. Use this form to start mail-order pharmacy services.
Request for Medicare Prescription Drug Coverage Determination. Use this form to request a coverage determination or exception to MediGold’s drug formulary.
Request for Redetermination of Medicare Prescription Drug Denial. Use this form to file an appeal related to your Part D prescription drug benefits.

Prior Authorization Form. You or your provider can use this form to request prior authorization for services that require it.

CVS Caremark Drug Claim Form. Use this form to be reimbursed for out-of-pocket covered prescription medication.
Direct Member Reimbursement Request Form. Use this form to request reimbursement for glasses after cataract surgery or other allowable medical expenses.

Last updated: 06/2024