Provider New/Update

Provider New/Update

Agency Name*

Request*

Select or enter value

Program(s)*

Select or enter value

I am enrolled in the CT Medical Assistance Program

Gainwell and GT Independence Approval Letters

Please include a copy of your approval/change letters from Gainwell (showing FULL AVRS ID #’s) and GT Independence for all programs affected. We cannot make any changes to our directory without confirmation of your enrollment/change.

File Upload*

Drag and drop files here or

Agency Address*

Agency Phone*

Agency Fax

After Hours Phone Number*

Billing Contact Name*

Billing Contact Email*

Name of Submitter*

Phone Number of Submitter*

Submission Date*

Connecticut Towns by Region

Please use this list of Connecticut Towns by Region to identify the specific towns in which you are willing to provide services by checking the box next to the individual town(s). If you cover all towns under a specific region, just select "All Towns." This will make our Provider Directory more user-friendly, efficient and accurate for locating potential providers.

CT - Statewide

CCCi- North Central

Select or enter value

CCCI - Eastern

Select or enter value

CCCI - Northwest

Select or enter value

AASCC - South Central

Select or enter value

SWCAAA - Southwest

Select or enter value

WCAAA - Western

Select or enter value

Corporate Office

43 Enterprise Dr., Bristol, CT 06010-7472 - 860-589-6226 - ctcommunitycare.org

Send me a copy of my responses

Privacy Notice|Report Abuse