Download the Form
Download and fill in excel spreadsheet with trip information.
Below you will find information and forms for healthcare facilities in Connecticut, including a tool to schedule multiple trips for multiple HUSKY Health A, C, and D Medicaid members at once. If you have additional questions or need assistance, please visit our support form.
If you’re looking to schedule transportation for several members at once, you can do so using the Multiple Trip Scheduling Tool.
Download and fill in excel spreadsheet with trip information.
Please note:
Complete the information below, attach the form, and submit.