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INSTRUCTIONS: CONNECTICUT INFERTILITY TREATMENT AND PROCEDURES DISCLOSURE FORM

Connecticut individuals seeking health insurance coverage for infertility treatment and procedures are required to file a form disclosing any previous such treaments for which they received coverage under a different insurance policy. This form can be found on the website maintained by the government of Connecticut.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 1: Enter the name of the individual seeking treatment on the first blank line, their date of birth on the second blank line, and their Social Security number on the third blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 2: Indicate whether you are covered as insured or as a dependent with a check mark.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 3: Enter the name of the insured on the fourth blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 4: Enter the current insurance carrier on the fifth blank line and your policy or ID number on the sixth blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 5: Indicate whether this is an individual or group plan with a check mark.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 6: If applicable, etner the group name on the seventh blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 7: Enter the date on which you began to be insured by the policy.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 8: If you have a secondary carrier, enter all information requested about them at the bottom of the first page.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 9: The first section of the second page concerns your previous carrier. Enter their name on the first blank line and the policy or identification number on the second blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 10: Provide the name of the insured, the group number (if applicable) and the beginning and ending dates of coverage. Indicate with a check mark whether the insured was covered as insured or as a dependent, whether this was an individual or group plan, and if this was a fully insured or self insured plan.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 11: Document previous treatment as instructed on the third page, then sign and date the bottom of the second page as instructed.