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

  1. Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
  2. 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
Download the PCMH Readiness Evaluation Questionnaire

Glide Path Application

  1. Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
  2. 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
Download the Glide Path Instructions and Application

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.

  1. Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
  2. Once you have contacted us, feel free to download the Glide Path Renewal Application
Download the Glide Path Renewal Instructions and Application

PCMH Application

  1. Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
  2. 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
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

  1. Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process

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.

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
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 (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).

Copyright © 2002-2023 State of Connecticut.

Privacy Statement   Disclaimer