HUSKY forms | Consumer fliers | Outreach fliers | Other resources
HUSKY forms
HUSKY application and renewal form: English and Spanish (PDF)
HUSKY/Charter Oak health plan enrollment form: English and Spanish (PDF)
W-38 Self-employment Income Verification Form: English and Spanish (PDF)
Release of information forms
These forms, signed by HUSKY applicants, give permission to the Department of Social Services and ACS to release information to organizations that help families apply for HUSKY. This enables community organizations to follow up on the status of applications.
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Consumer Fliers
HUSKY outreach flier
This flier encourages working families to apply for HUSKY for children, parents and pregnant women, and outlines available services. July 2008.
- English: PDF
- Spanish: PDF
- Brazilian Portuguese PDF
- Haitian Creole PDF
- Polish PDF
- Vietnamese PDF
What U.S. Citizens Need to Apply for HUSKY A
Plain language flier for families. PDF
Renewal fliers
Educates HUSKY members on renewing their HUSKY coverage.
Fliers for immigrants
- Health insurance can help you keep your family healthy English and Spanish (PDF)
- Legal immigrants and HUSKY: How to apply English and Spanish (PDF)
- Where can we go for health care if we can't get HUSKY? English and Spanish (PDF)
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Outreach Fliers (for community organizations and businesses)
Documents That Can Prove Citizenship & Identity for HUSKY A and Medicaid Applicants
List of documents that can meet Medicaid proof of citizenship requirements. PDF
Business outreach flier
Encourages businesses to inform their employees about HUSKY, if the business does not offer health coverage for all employees and their dependents. PDF
Child Support Cooperation Requirements and HUSKY PDF
Verifying HUSKY Eligibility PDF
How to help families keep HUSKY Coverage: extended medical benefits PDF
Legal Immigrants and HUSKY: Who is Eligible PDF
Effective HUSKY Outreach Messages
How can community organizations best promote the HUSKY health insurance program? What kind of messages have the most appeal to families? A fact sheet provides tips on effective outreach messages. PDF
Tips on Creating Easy-to-Read Materials for Consumers
Most health education materials are written at a level that many readers find difficult to understand. These fact sheets offer guidance on writing and designing materials that are easy to read. PDF
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Other Resources
HUSKY Income Guidelines
Annual and monthly income guidelines for children, parents, and pregnant women. May 2009. PDF
HUSKY Managed Care Organization Telephone List
To help providers and members access services, this is a listing of health plan phone contacts, including member services, provider relations, as well as mental health, dental, pharmacy, vision, and transportation vendors. December 2008. PDF
CT Department of Social Services Regional Office Information
Contact information for regional offices. November 2008. PDF
Community Health Centers in Connecticut
Directory of health centers. November 2008. PDF
Schedule of well-child visits
Fliers for health care professionals that summarize the EPSDT periodicity schedule. They outline when children need well child visits and immunizations.
- EPSDT Quick Reference Guide. January 2007. PDF
- Recommended Childhood Immunization Schedule, 2009 (from the Centers for Disease Control): PDF
- Well Care Exam Forms & Recommendations for Anticipatory Guidance - 27 pages - (from DSS, Feb 06) PDF
- Recommendations for Anticipatory Guidance only - 6 pages - (from DSS, Feb 06) PDF
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