Compliance Notification Form - Office of the State Comptroller - CT.gov

State of Connecticut
Health Enhancement Program
CO-1316 Revised 5/2012
COMPLIANCE NOTIFICATION FORM
State Of Connecticut
Office of the State Comptroller
Healthcare Policy & Benefit Services Division
55 Elm Street
Hartford, CT 06106-1775
www.osc.ct.gov
Important Information
The Health Enhancement Program rewards members for taking steps to help maintain good health or to achieve greater
health. One important step for members to remain eligible for program participation is to complete their regular health
screenings. There may be times when claims data is not available to identify a member’s completion of a requirement.
This form should be used to report information for those times where data was unavailable, but a requirement was in fact
already completed. There may also be times when a requirement cannot be completed due to medical reasons. If a
requirement cannot be met due to a special circumstance medical condition (for example, pregnancy, etc.) or if it is
medically unadvisable, you may also use this form to request an exemption.
If you were not notified of missing HEP requirements, then you do not need to use this form. Your health plan will
be able to automatically identify your completion of a requirement through claims submitted by your physician or provider.
INSTRUCTIONS FOR MEMBERS: Please complete the Member Information and the Provider Information sections of this
form. Please self-report your completion or scheduled completion of a physician visit or screening on page 2. Once
completed, please submit forms as noted below. Your form will be processed within 15 business days from receipt as
long as all required information is submitted. If you have questions regarding this form or the HEP program, please
contact your State-dedicated Member Services Department on the back of your medical carrier’s ID card.
Submit completed Compliance Notification forms to: Healthcare Analysis Unit, Office of the State Comptroller, 55
Elm Street, Hartford, CT 06106 or fax to: (860) 702-3556.
If your reported screening was processed through insurance outside of your state-sponsored health coverage or
if you are requesting an exemption you MUST also submit a Physician Notification form to your medical carrier.
Member Information (Required and must match exactly to what is listed on your Medical/Dental Plan ID card.)
Employee ID
Employee Last Name Employee First Name Middle Initial Date of Birth (MM/DD/YYYY)
/ /
Spouse Last Name Spouse First Name Middle Initial
Home Address – Number and Street Name City State Zip Code
Telephone
( ) -
Email Address
Medical Provider Information (Required)
Provider Name / Name of Clinic Provider ID # (If Applicable) Telephone Fax
( ) - ( ) -
Office Address – Number and Street Name City State Zip Code
Dental Provider Information (If Applicable)
Dentist / Provider Office Name Provider ID # (If Applicable) Telephone Fax
( ) - ( ) -
Office Address – Number and Street Name City State Zip Code

State of Connecticut – HEP – Compliance Notification Form
Page 2 of 2
Employee/Spouse Last Name Employee/Spouse First Name Middle Initial Date of Birth (MM/DD/YYYY)
/ /
Place Check Mark in Each
Applicable Box
Service or
Appointment
Date
(MM/DD/YY)
Completed/Scheduled Screening
Future
Appointment
Scheduled
Already
Completed
Already Completed
Processed With Coverage
Outside of State-Sponsored
Medical or Dental Insurance
Exempted
from
Screening
Preventive Well Visit Exam
Cholesterol Screening
Once every: 5 years (ages 20-29),
3 years (ages 30-39), 2 years
(ages 40-49) and every year (ages
50+)
/ /
/ /
I understand that I am responsible for submitting a
completed Physician Notification Form to be
considered compliant with HEP requirements.
I understand that I am responsible for submitting a
completed Physician Notification Form to be
considered compliant with HEP requirements.
Vision Exam
(Adults 19 and older, every other
year)
Clinical Breast Exam
(Females Only)
Adults 18 and older, once every 3
years
Mammography
Required for every female
between the ages of 35 and 39 or
as recommended by Physician
/ /
/ /
/ /
I understand that I am responsible for submitting a
completed Physician Notification Form to be
considered compliant with HEP requirements.
I understand that I am responsible for submitting a
completed Physician Notification Form to be
considered compliant with HEP requirements.
I understand that I am responsible for submitting a
completed Physician Notification Form to be
considered compliant with HEP requirements.
Colorectal Cancer Screening
Fecal Occult annually or
Colonoscopy every 10 years
Cervical Cancer Screening
(ages 21+)
One screening required every 3
years
/ /
/ /
I understand that I am responsible for submitting a
completed Physician Notification Form to be
considered compliant with HEP requirements.
I understand that I am responsible for submitting a
completed Physician Notification Form to be
considered compliant with HEP requirements.
Dental Cleaning(s)
(If enrolled in a State dental plan)
/ /
I understand that I am responsible for submitting a
completed Physician Notification Form to be
considered compliant with HEP requirements.
Employee/Spouse or Parent/Legal Guardian Signature
Date
X_____________________________________________________________
/ /