Corporate Office
127 Washington Avenue
East Building, 3rd Floor
North Haven, CT 06473
Phone (203) 562-7228
Fax (203) 624-6665 Operations Office
6 Corporate Drive, Suite 430
Shelton, CT 06484
Phone (203) 225-1291
Fax (203) 925-2652 Collaborative Accountable Care (CAC)
Election to Participate
This CAC Election to Participate ("Election") confirms the undersigned health care provider’s
(who is referred to as "You") agreement to participate in the Connecticut General Life Insurance
Company ("Cigna")Collaborative Accountable Care (“CAC”) program with CT State Medical
Society IPA, Inc. (“IPA”).
You understand that Your participation in the Cigna-IPA CAC will become effective upon
notice from IPA.
You understand and agree that if you are a Primary Care Physician (specialty of Family
Practice, General Practice, Internal medicine, pediatrics, OB-Gyn, Adolescent Medicine and
Geriatric Medicine) you may only participate in one Cigna-IPA CAC program at a time.
You acknowledge that Your Agreement through which you participate in the Cigna provider
network ("Participation Agreement") remains in full force and effect. Should your Participation
Agreement terminate for any reason, your participation in the Cigna-IPA CAC program
immediately and automatically terminates.
You acknowledge that Your participation in the Cigna-IPA CAC program immediately and
automatically terminates if the CAC agreement between Cigna and IPA terminates.
Date:
_________________________________
Signature:
_________________________________
Printed Name:
_________________________________
Email:
_________________________________
Office Contact Name/Email:
___________________________________________
Group Name:
__________________________________
Tax Identification Number:
_________________________________
In addition to this Election, please provide a list of all practitioners in your group. Return by Mail: CSMS‐IPA 6 Corporate Drive, Suite 430 Shelton, CT 06484 Return by Fax: Cindy Agosto 203‐925‐2652 Return by Email: Cindy Agosto Cagosto@csms‐ipa.com Building Partnerships Between Business and Medicine
www.csms-ipa.com

Health Insurance/Managed Care

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