Forms & Documents

Filling out forms and applications can be tedious. We can ensure that the process is smooth and is completed in a timely manner. Prior to completing and submitting any documents, please contact us at 203.949.4194 to ensure the submission of accurate and complete information.


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 below
  • 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
    • Download the PCMH Readiness Evaluation Questionnaire

PCMH Readiness Evaluation Questionnaire for Level 2 or Level 3 NCQA recognized practices

  • 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 below
  • IT IS IMPORTANT TO FOLLOW THESE INSTRUCTIONS:
    • 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
    • Download the Readiness Evaluation Questionnaire

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 Readiness Evaluation Questionnaire below
  • IT IS IMPORTANT TO FOLLOW THESE INSTRUCTIONS:
    • 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
    • Download the Glide Path Instructions and 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 below
  • IT IS IMPORTANT TO FOLLOW THESE INSTRUCTIONS:
    • 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
    • Download the PCMH Instructions and Application

PCMH and Glide Path Change request form

Please be sure to read all instructions prior to completing this form

  • Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
  • These revisions include:
    • Adding or removing a practitioner
    • Adding a new practice location address
    • Updating an existing PCMH or Glide Path practice address or
    • Updating/correcting a provider name

Attention: When adding a provider to your PCMH roster by completing a PCMH/GP Change form, claims previously paid for which enhanced rates are due will require you to complete a claim adjustment for each claim in question via HP’s Secure Web portal. Please note, these claims will be included in a future monthly HP re-processing project and will pay the enhanced rate at that time if you choose not to individually adjust these claims via the Secure Web portal at this time.

Download the PCMH and Glide Path Change Request Form

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 for the HUSKY Health Program. For the general HUSKY website gateway, please visit www.ct.gov/husky. HUSKY Health includes Medicaid and the Children’s Health Insurance Program, and is administered by the Connecticut Department of Social Services.