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This form is used for creating a biographical list of life and health insurance administrators in Arizona.
This Form is used for requesting an appeal for a healthcare decision in Arizona.
This document is a request for information form that is used when trying to gather information from a health insurer in Arizona. It is used to request specific details and documentation related to health insurance coverage.
This form is used for requesting an exception to coverage in the state of Colorado.
This form is also known as the healthcare marketplace tax form. It is used to inform the IRS about individuals and families enrolled in a health plan via the Health Insurance Marketplace.
This form is used for enrolling in a chip program in Mississippi.
This form is filed by employers with 50 or more full-time employees in order to provide information about their enrollment in health coverage required under sections 6055 and 6056 of the Internal Revenue Code.
This form is used for individuals in Arizona to apply for a Certificate of Eligibility for the Health Insurance Premium Tax Credit. It helps determine if an individual is eligible for a tax credit to help pay for health insurance premiums.
This form is used for requesting a hearing and providing notice regarding health insurance assignment in California, specifically for Korean speakers.
This document provides information about an increase in rates for health and accident insurance in the state of Mississippi.
This document is used for enrolling in a universal group outside of the Idaho Exchange in Idaho.
This document is a special authorization request form for low molecular weight heparin medication in Prince Edward Island, Canada.
This Form is used for applying to the Catastrophic Drug Program in Prince Edward Island, Canada. This program provides financial assistance to residents who require high-cost medications.
This document provides information about health coverage options available to employees in the state of New Mexico. It outlines the various plans and benefits offered and explains how employees can enroll and access these benefits.
This Form is used for updating health insurance information for individuals residing in New York.
This document is a checklist outlining the application requirements for becoming a Pharmacy Benefit Manager (PBM) in South Carolina. It contains the necessary information and steps that need to be followed to apply for PBM licensure in the state.
This Form is used for requesting prior authorization for otological medical procedures in the state of Wisconsin. It includes a physician report on the patient's condition and treatment plan.
This Form is used for attaching a spell of illness to a prior authorization request in Wisconsin.
This Form is used for applying to the T.J. Anthony Catastrophic Illness Program Family Member (CIP-FM) in the City and County of San Francisco, California.
This form is used for requesting reimbursement from a health care insurer in Texas for a payment made. Fill out the DWC026 form to request reimbursement.
This Form is used for filing health insurance claims in Washington state.