MedicaidAdministrativeLow impact
Revised W10 Form - Inter-Agency Patient Referral Report pdf
Connecticut Medicaid (HUSKY Health)·CT·Provider Bulletin
Effective date
Jun 1, 2023
We identified it
Jun 20, 2026
Summary
Connecticut Medicaid has updated the W-10 Inter-Agency Patient Referral Report form to promote inclusion and enhance safe care transitions. Providers can continue using old forms if they have them, but the Department will no longer print the old version.
Action Required
Providers currently using W-10 forms should download the updated electronic version from Applications and Forms (ct.gov) for future referrals. Contact Eva Forrest at eva.forrest@ct.gov with questions about the new form.