SSBCI 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 below attestation form online or download and mail/fax it to us.

Option 1: Online Form

Please visit the online SSBCI form by clicking the button below

Visit the Online Form

Option 2: Physical Form

Please download the SSBCI form by clicking the button below and return to us 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

Download the Form (PDF)

Provider Services is here to help

866-420-9332

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