Forms & Applications
Filling out forms and applications can be tedious. We can ensure that the process is smooth and is completed in a timely manner.
Important
Prior to completing and submitting any documents, please contact us at 203.949.4194 to ensure the submission of accurate and complete information.
Person-Centered Medical Home (PCMH) Readiness Evaluation Questionnaire
- Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
- Once you have contacted us, feel free to download the Readiness Evaluation Questionnaire
It is Important to Follow these Instructions After Contacting the PCMH Program Administrator
- Right click the link below and choose “Save Target as...” to download the file to your desktop
- Open the pdf from the desktop in Acrobat Reader and fill it out
- Once it is completed, save the file and click the submit button
Glide Path Application
- Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
- Once you have contacted us, feel free to download the Glide Path Instructions and Application
It is Important to Follow these Instructions After Contacting the PCMH Program Administrator
- Right click the link below and choose “Save Target as...” to download the file to your desktop
- Open the pdf from the desktop in Acrobat Reader and fill it out
- Once it is completed, save the file and click the submit button
Glide Path Renewal Application
The Glide Path Renewal option allows current Department of Social Services (DSS) PCMH approved practices to transition from an effective National Committee for Quality Assurance (NCQA) PCMH recognized status past their expiration date and continue participation as an approved PCMH practice in the DSS program. The enhanced rate will be adjusted and the practice can continue to receive assistance from our Clinical Practice Transformation Specialist (CPTS) team as they work towards re-recognition.
- Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
- Once you have contacted us, feel free to download the Glide Path Renewal Application
PCMH Application
- Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
- Once you have contacted us, feel free to download the PCMH Instructions and Application
It is Important to Follow these Instructions After Contacting the PCMH Program Administrator
- Right click the link below and choose “Save Target as...” to download the file to your desktop
- Open the pdf from the desktop in Acrobat Reader and fill it out
- Once it is completed, save the file and click the submit button
Secure emails
We’ve begun using new software for our secure emails.
During your first time sending or receiving an email with this system you’ll need to create an account with a new password. You'll use this information to log in each time you want to send a secure email. You'll also use it to log in when you receive a secure email from HUSKY Health. When creating your new account, you’ll receive an email from Proofpoint. Enter the code from the email in the field provided to complete your registration.
When sending your email, address it to provider@chnct.org for questions about reports, prior authorizations, the PCMH program, etc.
Address your email to websupport@chnct.org for help related to the provider portal, such as issues with resetting your password or accessing your account.
This portion of the HUSKY Health website is managed by Community Health Network of Connecticut, Inc.®, the State of Connecticut’s Medical Administrative Services Organization (ASO) for the HUSKY Health program. For the general HUSKY Health website gateway, please visit portal.ct.gov/husky. HUSKY Health includes Medicaid and the Children’s Health Insurance Program, and is administered by the Connecticut Department of Social Services (DSS).
