CONNECT Program Sign Up
Please fill out the following form to enroll your program into CONNECT. Once the form is completed, the CONNECT Coordinator will contact you.
Organization Information
Organization Name
*
Program Name
*
Enter the name of your program as it should be displayed in CONNECT. If you are operating out of a multi-program organization, each program will need to be added individually.
Agency Phone Number
*
Please enter a valid phone number.
Agency Fax Number
Agency or Program Description
*
This description will be included in CONNECT to provide an overview of your program.
Agency Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency Website
*
Does your organization serve any of the following special populations? (Mark all that apply)
*
Belknap Tribes of the Fort Belknap Reservation
Blackfeet Tribe of the Blackfeet Reservation
Confederated Salish & Kootenai Tribes of the Flathead Reservation
Crow Tribe of the Crow Reservation
Chippewa Cree Tribe of the Rocky Boy's Reservation
General Population
Individuals with Disabilities
Individuals Experiencing Homelessness
Little Shell Chippewa Tribe
LGBTQ Populations - Gender and Sexuality Affirming
Northern Cheyenne Tribe of the Northern Cheyenne Reservation
Pregnant Women
Service Members/Veterans
Youth
Other
Do any of the following descriptions match your agency? (Mark all that apply)
*
HIPAA Covered Healthcare Provider
Non-HIPAA Covered Provider
42 C.F.R Part 2 Program
School-based
Domestic Violence Response Provider
Non-healthcare and non-school-based
Other
Select all that your program accepts:
*
Aetna
Allegiance
Assurant Health
Blue Cross Blue Shield
Cigna
Clear One Health
First Choice Health
Health Comp
Humana
Indian Health Services
Insurance Not Required
John Alden Health
Masonry Welfare Trust
Medicaid
Medicaid/Medicare
Medicare
Montana Health Co-Op
N/A
No Cost for Service (Free)
PacificSource
Sliding Fee Scale
Standard Security Life
Time Insurance
Time Short Term Insurance
TriCare
TriWest
United Healthcare
WorldIns ExpressMed
Service(s) offered by program:
*
i.e Child Care, Parent Education, Chronic Disease, WIC/Food Support, etc.
Montana County/Counties Served
*
Include all counties where your program primarily offers services. If you offer services statewide, simply type "statewide"
Contact Information
Please list the name, job title, and email address of any employee who will need access and login credentials for CONNECT.
Contact Name(s), Job Title(s), and Email(s)
*
Please hit 'enter' after each new person. Add as many people from your organization as needed.
CONNECT Outreach
Are there organizations that you frequently exchange referrals with? Please provide the name and contact information of any agencies that you would like our team to contact about joining CONNECT.
Submit
Should be Empty: