Connecticut Facility Network

Connecticut Facility Network

Downloads

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 TitleDescription
Child Consent FormChild Consent Form
Child Consent Form - SpanishChild Consent Form - Spanish
Closest Provider CertificationCPC Form for Mileage
Companion Referral FormForm that is used to approve medical necessity for companions and aides
Covered/Non-Covered Service ListList of most common covered/non-covered services for Non Emergent Transportation
CT DSS Facility NEMT BrochureHow to Access Non-Emergency Medical Transportation
CT DSS Hospital NEMT BrochureHow to Access Non-Emergency Medical Transportation
CT DSS NEMT Brochure [Spanish]Como acceso No son de emergencia Transporte medico
CT Physician Transportation Restriction FormCT Physician Transportation Restriction Form
CT Single Trip RequestCT Single Trip Request
CT Standing OrderCT Standing Order
Facilities Gas Reimbursement clarification letterFacilities Gas Reimbursement clarification letter
Gas Reimbursement GuidelinesGas Reimbursement Guidelines
Gas Reimbursement Invoice FormGas Reimbursement Invoice Form
How to submit a complaintHow to submit a complaint
State MapA Map which shows the CT DSS Husky A, C and D Medicaid members service area

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