Chronic Condition Form
Our patients with certain health conditions or adverse health outcomes may be eligible for additional benefits as part of the Special Supplemental Benefits for the Chronically Ill (SSBCI). One of your patients has elected to enroll in a CCA Plan. To help determine if your patient is eligible, we’ll need some information from you. Please complete the attached attestation form and fax it to us at 413-733-1924 or mail:
Commonwealth Care Alliance
101 Wason Avenue, 3rd floor
Springfield, MA 01107
As a reminder members are eligible for an Annual wellness and/or physical exam once per year.
We’re here to help you promote good health for our members. If you have questions, please call our Provider Services team at:
- California: 866-333-3530
- Massachusetts: 866-420-9332
- Michigan: 855-959-5855
- Rhode Island: 866-420-9332
Step 1: Fill out the form
Please download the 2023 Chronic Condition Form by clicking the button below.
Step 2: Send to CCA
Once you’ve completed the entire training, please return it using one of the following options.
Fax the form:
413-733-1924
Mail the form:
Commonwealth Care Alliance
101 Wason Avenue, 3rd floor
Springfield, MA 01107