Commit to Connect Form

Welcome to Connie!
Fill out the Commitment to Connect form to start connecting with Connie!
This form is used by organizations interested in joining Connecticut’s statewide Health Information Exchange (HIE).

Connie, Connecticut’s Statewide HIE

A health information exchange, or HIE, is a safe electronic way for health care providers and organizations to share clinical information about their patients. By state statute, Connie was authorized to be an independent, not-for-profit, neutral, and trusted organization to develop and operate the statewide HIE in Connecticut (Conn. Gen. Stat. 17b-59d and 17b-59g).

Connie enables providers and physicians to:

• Better share clinical information across all healthcare settings.
• Support care coordination.
• Reduce preventable costs associated with readmissions and duplicative testing.
• Support public health reporting, research, and population health analytics.
• Adhere to and promote standards and interoperability.
• Provide patient access to their own health information.

Connie is a growing network comprised of hundreds of healthcare providers. As Connecticut’s official HIE, Connie is working to connect all of Connecticut’s providers, including hospitals, pharmacies, payors, health departments, state agencies, and health centers.

Participation Requirements

State statute requires hospitals and labs to connect to Connie within one year and all other healthcare providers have two years from Connie’s date of being operational. According to the statute, upon the HIE being deemed operational, specific requirements for connecting go into effect for hospitals licensed under chapter 368v, clinical laboratories licensed under section 19a-30, and healthcare providers defined as an individual, corporation, facility, or institution licensed by the state to provide healthcare services (Conn. Gen. Stat. 17b-59e).

The Office of Health Strategy (OHS) has announced that Connie is operational as of May 3, 2021.

What it means to “connect” and “participate”

To meet the state’s mandate, an organization is connected when its clinical and demographic information is being sent to Connie.

What are the deadlines for meeting this mandate?

• Hospitals and clinical laboratories are required to begin the connection process within one year of operations (May 3, 2022)

• Healthcare providers are required to begin the connection process within two years of operations (May 3, 2023)
How to Connect

Filling out this form initiates the process of connecting to Connie.

The process includes the following steps, with anticipated time frames:

1. Legal Onboarding (1 month): identify, negotiate, and sign the appropriate legal agreements which Connie will provide to organizations within ten days of submitting the signed Commitment to Connect form.

2. Technical Onboarding (2 months): work with Connie’s technical team to create the technical connection needed to facilitate data exchange.

3. Access data (2 months): determine data viewing preference, establish integration (where needed), provide training to end users (when needed).
Commitment to Connect to Connie Form
Completing this form and returning it to Connie serves as documentation of your organization’s application to connect to, and participate in, the statewide HIE as required by Conn. Gen. Stat. 17b-59e. Organizations are expected to proceed in good faith with the steps outlined above to complete their requirement under the mandate. *

I understand and have read the terms and conditions above
Is your organization licensed to provide health care services in the state of Connecticut? *

No Yes
Is your organization a community-based organization? *

No Yes
Please describe your community-based healthcare organization *
If eligible, would your organization like to participate in the DSS ARPA Home and Community-Based Services (HCBS) program?

No Yes
Click here for more information on HCBS program requirements.
What is your Federal Tax ID number? *
Please select your organization's type and subtype below

Select only one subtype under the organization type that most closely describes your organization.
Accountable Care Organization (Select ONE option as applies)

Yes
Ambulatory (Select ONE option as applies)

Audiology Behavioral Health Behavioral Health with 42 CFR Pt. 2 Dentistry FQHC Optometry Pediatrics Primary Care Rural Health Clinic Specialty Practice Other - Please fill in the box
Care Coordinator/Management (Select ONE option as applies)

Care Coordination Entity Other - Please fill in the box
Care Transformation Organization (Select ONE option as applies)

Yes
Clinically Integrated Network (Select ONE option as applies)

Independent Physician Association (IPA) Other - Please fill in the box
Community-Based Organization (Select ONE option as applies)

Long Term Services and Support (LTSS) Social Determinants of Health Other - Please fill in the box
First Responder (Select ONE option as applies)

EMS Other - Please fill in the box
Government or Government Affiliation (If "Yes" please type in which organization you are affiliated with in the comment box below.)

Yes No
Hospital (Select ONE option as applies)

Acute Care Critical Access Freestanding Emergency Department Freestanding Medical Facility Psych Hospital Federal Government Rehab Hospital Other - Please fill in the box
Laboratory (Select ONE option as applies)

Yes
Long Term/Post-Acute (Select ONE option as applies)

Assisted Living Facility Home Health Care Hospice Rehab Skilled Nursing Other - Please fill in the box
Payer (Select ONE option as applies)

Managed Care Organization (MCO) Medicare Advantage (MA) Administrative Service Organization (ASO) Care Management Program Private Other - Please fill in the box
Pharmacy (Select ONE option as applies)

Yes
Radiology Center (Select ONE option as applies)

Yes
Urgent Care (Select ONE option as applies)

Yes
Health System (Select ONE option as applies)

Yes
Other Industry Types (Select ONE option as applies)

Network Connector Veterinarian Vendor Research Affiliate Dialysis Other - Please fill in the box
Official Business Name *
Affiliations (Please list all that apply) *
e.g., hospital, accountable care organization (ACO), clinically integrated network (CIN), independent physician association (IPA)
Business Website *
Business Phone *
Main Office Address *
Organization NPI *
Full name of person responsible for signing agreements *

First Name Last Name
Contact E-mail Address *
Contact Title *
EHR Vendor and Product Name

EHR Vendor EHR Product Name
Do you use the following lab(s):

LabCorp Quest Other – please fill in the box.
Size of Health Care Organization (number of CT licensed health care providers) *
We're ready to go! Please send a copy of the legal agreements for connecting to Connie. *

Yes
We would like more information. Please send a meeting invitation to the next Connie Overview and How to Connect Zoom meeting (held on the last Wednesday of every month at noon).

Yes
Please provide contact information for the person to be invited to the Connie Overview and How to Connect Zoom meeting:

First Name Last Name
Email of person invited to the Connie Overview and How to Connect Zoom meeting:
example@example.com
Please verify that you are human *
By filling this form, I am granting Connie permission to send information to my email address.
Should be Empty:

Welcome to Connie!

Fill out the Commitment to Connect form to start connecting with Connie!