You told us that someone in your home pays medical bills. Please answer the questions to tell us more about the medical expenses.
Select the type of medical expense.
Enter the name of medical care provider.
Enter the dates of service.
Select how frequently the of medical expense is paid.
Enter Yes if expenses are for Labor and Delivery.
Enter Yes if you are a hospital or other medical provider seeking payment for emergency medical services provided to a patient who is ineligible for full HUSKY coverage due to their immigration status
Enter the amount paid.
If the medical bill is paid in full, please choose Yes.
Enter the amount pending on the bill.
If the person listed on the page pays other medical bills, select Yes. If they don't, select No.
To close this window and return to ConneCT without saving, click the CANCEL & EXIT button.
To save your application and return to ConneCT, click the SAVE & EXIT button.