Skip to primary navigation Skip to main content


Medicare is a government funded health insurance program for individuals 65 or older.  It also applies to individuals who may be any age under 65 but with certain specific disabilities or permanent kidney failure. There are four separate programs that make up Medicare benefits: Medicare Part A (hospital insurance), Part B (supplementary Medical Insurance), Part C (Medicare Advantage Plans) and Part D (prescription drug coverage).

For an in-depth look at the various Medicare programs and benefits, please visit the official website for the Centers for Medicare and Medicaid Services (CMS) at CMS is the federal agency that administers Medicare and their website is a very useful, informative and easy-to-use resource where many beneficiaries will find the answers to Medicare-related questions and inquiries.

Constituents are encouraged to visit before opening a case with our office as this may be the most efficient way to address your concerns and find answers to your questions.  If CMS is not able to resolve your issue, please fill out the online form and privacy release below.  Please print, sign and send the privacy release to my Hartford office.  Once it is received, a member of my Constituent Services team will contact you to discuss how we can best help you resolve your issue.  Please allow up to two weeks from the time we receive your privacy release for my office to contact you.

If your issue is urgent or time sensitive, please call my Hartford office at 860-258-6940.

Preview and Submit

This is a preview of your Request. Please confirm that all of the information below is correct before submitting. If you would like to make any changes to the information you have provided, please use the "Edit" button below. Using your browser's buttons to navigate will cause all form information to be lost.

Primary Contact Info

Your Name
Your Contact Information

Federal Agency Information

Federal Agency Information
  1. Cntrs for Medicare and Medicaid Services

Additional Information

Additional Information
  1. Social Security No. format: XXX-XX-XXXX
Medical Provider Information

Description of Request

Your Request
  1. (please describe the problem in as much detail as necessary)

Preview and Send Request

Please click on the Preview button to review any information you have entered on this page.

Once you have reviewed your information on the next page, press the Print and Submit button. This will generate a PDF containing all of the information you have entered as well as a privacy release form. Please print the form, sign and date the last page, and return the form in its entirety to my Hartford office by fax or mail.

Although the information on your form will be submitted to my office electronically, we cannot open an inquiry on your behalf until we receive your signed form.


Preparing PDF...

Thank you for contacting me. The information on your form has been submitted electronically to my office. A PDF of your form is being generated automatically and should be ready within 10 seconds. If one is not available to download in that time, click here.

Once we have received your signed authorization, my staff will begin assessing how we can help. Please allow up to 30 days from the day we receive your release for my office to contact you. Thank you.