Application Submission Methods

There are two ways to submit your application documents. Please choose the one that works best for you.

1. Online Application (Recommended)

This is the fastest and most direct way to submit your application. The CS Member Summary form can be downloaded, filled out and uploaded but since the data does need to be inputted through the online portal (by the Connections staff) consider using the online form for the quickest processing for the application.

Start Online Application

2. Manual Download & Upload

If you prefer to work offline, you can download the blank forms below, complete and sign them, and then upload them all through the secure portal at the bottom of this section. For security and HIPAA compliance do not email completed forms, instead use our secure upload portal below.

Print Blank Forms

Print individual forms:

CS Member Summary Program Information & Acknowledgment HIPAA Authorization Liability Waiver Freedom of Choice Waiver Declaration of Eligibility (for SNF Diversion only)LIC 602A - Physician's Report

Secure Document Upload Portal

Use this form to securely upload your completed and signed documents without needing to log in.

Step 1: Provide Your Information

Your Full Name

Your Email Address

Member's Full Name

Member's Medical Record Number (MRN)

Member's Health Plan

Step 2: Upload Documents

For each required document, click "Download" to get the blank form if needed, then "Upload File" to submit the completed version. You can upload multiple files for different documents before submitting.

CS Member Summary

Download Blank Form

Upload File

Proof of Income (Social Security letter or 3 months bank statements)

Upload File

Medicine List

Upload File

Bundle Uploads

Waivers Bundle (HIPAA, Liability, Freedom of Choice)

Download the full package, get the waivers signed, and upload them here as a single file.