Fillable Medical Records Request Form (Commercial/Medicare Advantage)

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Medical Records Request Form (Commercial/Medicare Advantage)

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The Medical Records Request Form (Commercial/Medicare Advantage) form is 1 page long and contains:

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  • 4 check-boxes
  • 13 other fields

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File type: PDF

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Proprietary information of ConnectiCare. © 2021 ConnectiCare, Inc. & Affiliates
Page 1 of 1
Medical Records Request Form
(Commercial/Medicare Advantage)
INSTRUCTIONS:
• This form is required when submitting medical records requested by ConnectiCare.
• This form should not be used for appeals.
• Be sure to use a separate form for each request.
• If you are sending more than 100 pages, please use a compact disc (CD), if available,
for your submission.
• Send completed form to: ConnectiCare
Attn: Payment Integrity
175 Scott Swamp Road
Farmington, CT 06034-0546
Fax: 1-212-510-4903
Date requested:
NDC#, CPT or
HCPC, if available:
Claim number:
Date(s) of service
(to – from):
Provider name:
Member name:
Contact name:
Member ID:
Contact phone:
Did you receive any medical record request for the claim noted above?
Please select “yes” or “no” below.
Yes
If known, please select the reason for the medical records/itemized bill request:
Payment integrity review
Specialized Investigations Unit
Claim denial (indicate denial code below)
Coding review
Other: (Please explain and be as specific as possible.)
No: (Please explain reason for submission.)
If you have any questions, please call Provider Services at 1-800-828-3407.
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Medical Records Request Form (CommercialMedicare Advantage)

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Completed 30 August 2021

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