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Consumer inquiries can be submitted to OHS 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 Health Strategy (OHS)
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 Health Strategy (OHS), 450 Capitol Avenue, MS#510HS, 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: ____________________________
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Guidelines and Required Information