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Federal Poverty Level Discount (FPL) Application

Federal Poverty Level Discount (FPL) Application

 

INSTRUCTIONS: ALABAMA FEDERAL POVERTY LEVEL ASSISTANCE APPLICATION (FPL) (Form 2G)

 

 

Alabama public education employees who have a combined family income less than or equal to 200% of the Federal Poverty Level may apply for assistance. To do so, they must be enrolled in the state's Public Education Employees' Health Insurance Plan. Form 2G, used to request assistance, is located on the website of the Retirement Systems of Alabama. This document can also be used to request children's health insurance.

 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 1: The first section concerns subscriber information. Enter your Social Security number and name on the first line.

 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 2: On the second line, enter your mailing address, city, state and zip code. 

 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 3: On the third line, enter your home and work phone numbers.

 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 4: On the fourth line, indicate whether you are married, single, divorced, legally separated or widowed with a check mark.

 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 5: The next section is only for those seeking children's health insurance. Indicate with a check mark whether any children are enrolled in Medicaid. If yes, give their names.

 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 6: A table is provided to list all household members. On line A of the first column, enter the name of the subscriber. On line B, enter the name of their spouse. On lines C through F, list all children under age 19 living in your household.

 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 7: In the second column, provide all listed household members' Social Security numbers.

 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 8: In the third column, provide all listed household members' dates of birth.

 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 9: In the fourth column, provide all listed household members' gender. 

 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 10: In the fifth column, describe the relationship to you of all listed household members. Enter your requested effective date and answer all remaining questions as instructed.

 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 11: Sign and date the form. 

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WC Assessment Form WCC10

WC Assessment Form WCC10

 

INSTRUCTIONS: ALABAMA ASSESSMENT REPORT FOR INSURANCE COMPANIES, SELF-INSURERS AND GROUP FUNDS (WCC Form 10)

 

 

Alabama insurance companies, group funds and self-insured businesses must file a WCC Form 10 on an annual basis. This form can be obtained from the website of the Alabama Department of Labor.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 1: Enter your company name.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 2: Enter the name of a contact person.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 3: Enter your mailing and physical address.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 4: Enter your NCCI, FEIN, SI and GSI numbers.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 5: Enter your telephone number.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 6: Enter any subsidiaries if you are a self-insured company.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 7: Enter your total compensation paid.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 8: Enter your total medical costs paid.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 9: Enter your total attorney fees paid.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 10: Enter your total administrative expenses paid.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 11: Enter your total court settlements paid.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 12: Enter the total of all these expenses.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 13: Print your name where indicated.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 14: The bottom of the form must be completed in the presence of a notary public. Print your name again and enter your corporate title.

 

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 15: Sign the form and give your title.

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Revoke Election Form IB09

Revoke Election Form IB09

 

INSTRUCTIONS: ALABAMA REVOKE ELECTION FORM STATE EMPLOYEES' HEALTH INSURANCE COVERAGE (Form IB09)

 

 

To cancel dependent coverage included in Alabama state employees' health insurance coverage, a form IB09 should be used. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 1: Print your name on the first blank line.

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 2: Enter your contract number on the second blank line.

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 3: Enter your work telephone number on the third blank line.

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 4: Enter your agency name on the fourth blank line.

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 5: Check the line next to the first statement if you have added dependents through marriage, birth or adoption of a child. Check the line next to the second statement if you have lost dependents.

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 6: The next five statements concern various changes in the employment status of you or your spouse. Check the line next to any applicable statements.

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 7: Check the next line if the dependant has lost coverage due to their age.

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 8: Check the next line if you are documenting a change of residence or worksite.

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 9: Check the next line if you are complying with a family relations judgment, decree or order.

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 10: Check the next line if revoking coverage due to a Medicare or Medicaid entitlement.

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 11: Check the next line if taking leave under the Family and Medical Leave act.

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 12: Check any of the next three lines if applicable. 

 

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 13: On the next blank line, enter the date on which the qualifying event occurred. Sign and date the bottom of the page.

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Annual Insurance Return 2013

 

INSTRUCTIONS: NEVADA ANNUAL INSURANCE PREMIUM TAX RETURN (Form IPT-R)

 

 

Nevada premium tax payments are submitted on an annual basis using the form discussed in this article. This document can be obtained from the website of the Nevada Department of Taxation.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 1: In the top right-hand corner, enter your tax identification number, federal ID, premium tax, retaliatory tax and total remittance.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 2: On line 1, enter your total premiums and consideration.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 3: On line 2, multiply line 1 by 3.5% and enter the resulting product. If a qualified risk retention group, multiply line 1 by 2% and enter the resulting product.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 4: On line 3a, if you qualify, calculate your home office credit as instructed.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 5: If qualified, enter the amount of ad valorem taxes paid on line 3b.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 6: Enter the maximum credit allowed on line 3c.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 7: Enter your allowable home office credits on line 3d.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 8: Subtract line 3d from line 2. Enter the resulting difference on line 4.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 9: Enter your life/health guaranty association offset on line 5.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 10: On line 6, enter your property/casualty guaranty association offset.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 11: On line 6A, enter the total overpayments applied from previous years.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 12: On line 6B, enter the total overpayments refunded by Nevada for the year specified.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 13: On line 7, enter your net premium tax due.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 14: If filing late, calculate your penalty and daily interest due on lines 8 and 9 as instructed.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 15: Add lines 7 through 9. Enter the resulting sum on line 10.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 16: Sign and print your name. Enter the date, your email address and telephone number.

 

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Retired State Employee Plan Change Form IB15

Retired State Employee Plan Change Form IB15

 

INSTRUCTIONS: ALABAMA RETIRED EMPLOYEE PLAN CHANGE FORM (Form IB15)

 

 

Retired Alabama employees of the state can change their health insurance coverage by filing a form IB15. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

 

Alabama Retired Employee Plan Change Form IB15 Step 1: At the top of the form, check the box next to the type of coverage you wish to obtain.

 

Alabama Retired Employee Plan Change Form IB15 Step 2: On the first line, provide your name, sex and the effective date of your current coverage.

 

Alabama Retired Employee Plan Change Form IB15 Step 3: On the second line, provide your Social Security number and date of birth.

 

Alabama Retired Employee Plan Change Form IB15 Step 4: On the third line, provide your street address.

 

Alabama Retired Employee Plan Change Form IB15 Step 5: On the fourth line, provide your city, state and zip code.

 

Alabama Retired Employee Plan Change Form IB15 Step 6: On the fifth line, provide your email address, as well as your work and home phone numbers.

 

Alabama Retired Employee Plan Change Form IB15 Step 7: If you are seeking to enroll in basic medical coverage administered under the Blue Cross SEHIP program, you must document your dependents. On the first line, enter the name of your husband or wife. Indicate which they are by circling the appropriate label and enter their birthdate and Social Security number. 

 

Alabama Retired Employee Plan Change Form IB15 Step 8: On the remaining lines, provide the same information for any sons, daughters, stepsons or stepdaughters.

 

Alabama Retired Employee Plan Change Form IB15 Step 9: If you are seeking to obtain Southland Optional coverage for hospital indemnity or vision, dental or cancer treatment, you must complete the last section. On the first line, enter the name of your current health insurance company, the name of the contract holder, the insurance policy and group numbers, and the name of the employer providing this coverage.

 

Alabama Retired Employee Plan Change Form IB15 Step 10: The second line asks if dental coverage is available under this retirement plan. Circle "Yes" or "No."

 

Alabama Retired Employee Plan Change Form IB15 Step 11: If dental coverage is provided, provide all information requested about it on the last line. Sign and date the bottom of the page.

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Annual IIPT(WC) Reconciliation 2013

 

INSTRUCTIONS: NEVADA ANNUAL INSURANCE PREMIUM TAX RETURN (Form IPT-R)

 

 

Nevada businesses and residents pay their annual insurance premium tax using the form discussed in this article. This form can be obtained from the website of the Nevada Department of Taxation.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 1: In the top right-hand corner, enter your tax identification number, federal ID, premium tax, retaliatory tax and total remittance.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 2: On line 1, enter the total premium tax and considerations.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 3: On line 2, follow the directions to determine the gross premium tax owed.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 4: If qualified, calculate the amount of home office credit applicable on line 3a as instructed.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 5: If qualified for this credit, enter the amount of ad valorem taxes paid on line 3b.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 6: If applicable, enter the maximum credit allowed on line 3.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 7: On line 3d, enter your allowable home office credits.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 8: Subtract line 3d from line 2. enter the resulting difference on line 4.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 9: Enter the life/health guaranty association offset on line 5.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 10: Enter the property/casualty guaranty association credit on line 6.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 11: Enter total overpayments applied from previous years on line 6A.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 12: Enter total overpayments refunded by Nevada for the year listed on line 6B.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 13: Enter your net premium tax due on line 7.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 14: If filing late, calculate your penalty due as instructed on line 8.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 15: If filing late, calculate the interest owed as instructed on line 9.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 16: Enter the sum of lines 7 through 9 on line 10.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 17: Sign and print your name. Provide the date, your phone number and email address.

 

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Southland Vision Enrollment/Cancellation Form IB20

Southland Vision Enrollment/Cancellation Form IB20

 

INSTRUCTIONS: SOUTHLAND NATIONAL SUPPLEMENTAL VISION INSURANCE ENROLLMENT/CANCELLATION FORM (Form IB20)

 

 

Alabama state employees who wish to enroll in state-administered supplemental vision insurance do so by filing a form IB20. This document can be obtained from the website of the Alabama State Employees' Insurance board.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 1: On the first line, enter your name, sex, and the date you wish for the coverage to take effect.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 2: On the second line, give your Social Security number and date of birth.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 3: On the third line, give your mailing address.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 4: On the fourth line, give your city, state and zip code.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 5: On the fifth line, give your home and work telephone numbers. 

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 6: On the sixth line, give your email address.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 7: In the box on the right, indicate with a check mark if you are seeking single or family vision coverage or whether you are filing this form to cancel coverage currently in effect.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 8: If you are seeking family coverage, you must detail your dependents. In the first column on the first line, enter the first name, middle initial and last name of your husband or wife. In the second column, circle "Husband" or "Wife" as applicable. In the third column, enter their date of birth. In the fourth column, enter their Social Security number.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 9: The next three lines require you to enter the same information for any sons, daughters, stepsons or stepdaughters.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 10: The last two lines provided require you to enter the same information for any grandsons, granddaughters, nephews and nieces.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 11: Sign and date the bottom of the first page. Mail the completed document to the address at the bottom of the second page.

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Annual Reconciliation Insurance Return 2013

 

INSTRUCTIONS: NEVADA ANNUAL INSURANCE PREMIUM TAX RECONCILIATION RETURN (Form IPT-R)

 

 

If required to file Nevada quarterly insurance premium tax returns during the year, an annual reconciliation form must be filed. This document can be found on the website of the Nevada Department of Taxation.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 1: In the top right-hand corner, enter your tax identification number, federal ID, premium tax, retaliatory tax and total remittance.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 2: On lines 1 through 4, enter your reported and actual quarterly taxable premiums for the quarters listed.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 3: Enter the total of the figures on lines 1 through 4 on line 5.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 4: On line 6, enter your total premiums and consideration.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 5: On line 7, calculate your gross premium tax as instructed.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 6: If you qualify, calculate your home office credit as instructed on line 8a.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 7: If you qualify for a home office credit, enter the amount of ad valorem taxes paid on line 8b.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 8: Enter the maximum credit allowed on line 8c.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 9: Enter the allowable home office credit on line 8d.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 10: Subtract line 8d from line 7. Enter the resulting difference on line 9.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 11: Enter the life/health guaranty association offset on line 10 and the property/casualty guaranty association credit on line 11.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 12: Enter total payments made with your quarterly payments on line 12. Do not include penalties or interest.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 13: On line 13, enter any overpayment and specify the year.

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 14: On line 14, enter the net premium tax due. 

 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 15: Complete the rest of the form as instructed.

 

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Health Insurance Enrollment IB02 – New employees only

Health Insurance Enrollment IB02 - New employees only

 

INSTRUCTIONS: ALABAMA HEALTH INSURANCE ENROLLMENT FORM (Form IB02)

 

 

Alabama state employees file for health insurance for themselves and qualifying dependents using a form IB02. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

 

Alabama Health Insurance Enrollment Form IB02 Step 1: Indicate with a check mark if you are filing for basic medical coverage, secondary supplemental coverage, optional policies for vision, dental and hospital indemnity, or if you are declining coverage.

 

Alabama Health Insurance Enrollment Form IB02 Step 2: Enter your full name and sex.

 

Alabama Health Insurance Enrollment Form IB02 Step 3: Enter your Social Security number and date of birth.

 

Alabama Health Insurance Enrollment Form IB02 Step 4: Enter your street address, city, state and zip code.

 

Alabama Health Insurance Enrollment Form IB02 Step 5: Enter your home and work telephone numbers, as well as your email address.

 

Alabama Health Insurance Enrollment Form IB02 Step 6: Enter the date on which you are requesting that coverage take effect for dependents.

 

Alabama Health Insurance Enrollment Form IB02 Step 7: The next section requires you to list all dependents you are seeking coverage for. Enter their name, indicate their relationship to you with a check mark, and provide their date of birth and Social Security number. Note that you cannot obtain coverage for a divorced or common-law spouse.

 

Alabama Health Insurance Enrollment Form IB02 Step 8: If you have additional group health insurance, indicate whether it has a spousal-carve out.

 

Alabama Health Insurance Enrollment Form IB02 Step 9: Enter the name of the company providing this insurance.

 

Alabama Health Insurance Enrollment Form IB02 Step 10: Enter the name of the contract holder and the policy number.

 

Alabama Health Insurance Enrollment Form IB02 Step 11: Enter the group number and the name of the employer providing this insurance.

 

Alabama Health Insurance Enrollment Form IB02 Step 12: Indicate with a check mark whether this plan includes dental coverage. If so, you must give the name of the dental insurance company, the policy and group number, and the name of the providing employer.

 

Alabama Health Insurance Enrollment Form IB02 Step 13: The section at the bottom left should be completed by your current employer.

 

Alabama Health Insurance Enrollment Form IB02 Step 14: Sign and date the form at the bottom right.

 

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Provider Screening Form IB13

Provider Screening Form IB13

 

INSTRUCTIONS: ALABAMA PROVIDER SCREENING FORM (Form IB13)

 

 

Alabama state employees who choose not to participate in Worksite Wellness screenings may instead submit health screening results through a healthcare provider. This is done using a form IB13. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

 

Alabama Provider Screening Form IB13 Step 1: Section 1 should be completed by the employee. In the first blank box, enter your name.

 

Alabama Provider Screening Form IB13 Step 2: In the second blank box, enter the screening date.

 

Alabama Provider Screening Form IB13 Step 3: In the third blank box, indicate whether you are male or female with a check mark.

 

Alabama Provider Screening Form IB13 Step 4: In the fourth blank box, enter your age.

 

Alabama Provider Screening Form IB13 Step 5: In the fifth blank box, enter your contract number.

 

Alabama Provider Screening Form IB13 Step 6: In the sixth blank box, enter your Social Security number.

 

Alabama Provider Screening Form IB13 Step 7: In the seventh blank box, enter your date of birth.

 

Alabama Provider Screening Form IB13 Step 8: In the eighth blank box, enter your daytime telephone number.

 

Alabama Provider Screening Form IB13 Step 9: Indicate your race or ethnicity with a check mark.

 

Alabama Provider Screening Form IB13 Step 10: Indicate with a check mark whether you have or have been told you have high cholesterol, high blood pressure or diabetes.

 

Alabama Provider Screening Form IB13 Step 11: Indicate with a check mark whether you take any medication for the conditions listed in step 10.

 

Alabama Provider Screening Form IB13 Step 12: The second section should be completed by your health care provider. They will detail your blood pressure, total cholesterol, HDL and LDL cholesterol, triglycerides, blood glucose, height, weight, body mass index, waist measurement, and waist/height ratio.

 

Alabama Provider Screening Form IB13 Step 13: On the next blank line, the provider should print their name.

 

Alabama Provider Screening Form IB13 Step 14: On the next blank line, the provider should enter their signature.

 

Alabama Provider Screening Form IB13 Step 15: On the next blank line, the provider should enter their address.

 

Alabama Provider Screening Form IB13 Step 16: The completed form should be returned to the State Employees' Insurance Board at the address given at the bottom of the page.

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