Guidelines and Required Information
 
Consumer inquiries can be submitted to OHCA on the
CAP Form. To download the CAP Form click here... for MS Word version and click here... for fillable PDF version.
 
If you are having difficulties downloading the form, a handwritten letter will be acceptable. We ask that the letter contain the same information requested on the form. See below for a sample form.
 
Be advised that information missing on the form or the handwritten letter may delay the processing of your inquiry and that, as a consumer of health services, you are entitled to an itemized copy of your hospital bill that details all of the services and supplies that you received. The line-item bill should outline every service provided, the date it was provided, and should include item and procedure codes.

In order to facilitate this process, please submit the form or handwritten letter to:

Office of Heath Care Access (OHCA)

Department of Public Health

410 Capitol Avenue, MS#13HCA

P.O. Box 340308

Hartford, CT 06134

OHCA@ct.gov

 

Sample-CAP Form

 

Patient Information:

Date: ____________

First Name: _____________ Middle Initial: ____ Last Name: _____________

Address:

Street: ______________________

City, State, Zip Code: _______________________________________________

Email: _________________

 

Hospital Name: ____________________________________

Hospital Date(s) of Service: ___________________________

Have you contacted the Hospital? Yes___   No___

If yes, provide a contact person and copies of any correspondence

 

Have you contacted any other State of Connecticut Agencies (i.e. Dept. of Insurance, Dept. of Public Health, and Office of Health Advocate)? Yes___ No___

If yes, provide the name of the contact person: ______________________and copies of any correspondence

 

Patient insurance, please check one:  Commercial  ? name:  ______________  

 

Uninsured ?   Medicaid ?     Medicare ?     Managed Care Medicare ? name: ____________

 

Managed Care Medicaid ? name: ____________    

 

Did your insurance cover a portion of the bill? Yes___ No____

 

Do you have a formal payment arrangement with the Hospital? Yes____ No____

 

Bill status:  In Collection:  Yes ___ No___

 

Provide a copy of your itemized Hospital bill redacted for confidential information such as Social Security number, date of birth, and Medical records number (the line-item bill should outline every service provided, the date it was provided, and should include item and procedure codes) and a description of your complaint with this form. If you choose not to email the form or Hospital bill, you could fax them to (860) 418-7053 or mail them to: Office of Heath Care Access (OHCA),Department of Public Health, 410 Capitol Avenue, MS#13HCA, P.O. Box 340308, Hartford, CT 06134.

 

Patient’s signature: ______________________    Date: _________________

 

If acting on behalf of the patient please indicate the following:

 

Name: ______________    Relationship to the Patient: _______________

 

Contact information:

Address: ___________________________________

Phone: __________________________ Email address (if available):_____________________

Signature: ____________________________