Providers, please use one of the forms to identify your point of contact for the RAC audit. Contact information will be used by Connolly Healthcare for all RAC program related correspondence, including but not limited to demand letters and medical record request letters.

Complete the form below for each of your serving providers and fax back to 203.529.2995:
> Download the provider contact form  [Download pdf]


For those serving many providers/NPIs you may choose to download the Excel spreadsheet version below. Fill in the fields within the spreadsheet and email back to: RACinfo@connollyhealthcare.com:
> Download the multi-provider contact spreadsheet  [Download Excel document]

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Connolly Healthcare correspondence can be clearly identified via the official Connolly Healthcare CMS letterhead.

Sample Connolly Correspondence:

> Automated Review Demand Letter  [Download pdf]

> Complex Review Demand Letter  [Download pdf]

> Additional Documentation Letter  [Download pdf]