INSTRUCTIONS: CONNECTICUT PSYCHIATRIC/SUBSTANCE ABUSE MEDICAL REPORT (Form P-142P/S)

When the Connecticut Department of Motor Vehicles receives a report that a driver may be unable to safely operate a vehicle due to abuse of medication, they will be required to receive an evaluation from a physician. The results of this evaluation will be documented and submitted on a form P-142P/S, which can be found on the website of the government of the state of Connecticut.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 1: Enter the date of the incident being addressed where indicated.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 2: The patient should enter their signature and the date in the first two blank boxes, then turn the form over to the medical professional conducting the evaluation, who will complete the rest of the form.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 3: Enter the patient's name in the first blank box, their date of birth in the second blank box, and their telephone number in the third blank box.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 4: Enter the patient's address in the fourth blank box.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 5: Enter the date of the last patient examination in the fifth blank box.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 6: In the next section, indicate the type of medication the patient is taking by placing a check mark next to the applicable medications.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 7: In the next section, document up to three medications being taken that are relevant to motor vehicle operation. Enter the name of the medication in the column on the left and the dose taken in the column on the right.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 8: Indicate with a check mark whether the patient currently suffers from convulsive seizures. If yes, give the date of their last seizure.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 9: Indicate with a check mark whether you believe the patient understands the risk posed by their condition that can affect their operation of a motor vehicle.

Connecticut Psychiatric/Substance Abuse Medical Report P-142P/S Step 10: Complete the rest of the form as instructed.

INSTRUCTIONS: CONNECTICUT INFERTILITY TREATMENT AND PROCEDURES DISCLOSURE FORM

Connecticut individuals seeking health insurance coverage for infertility treatment and procedures are required to file a form disclosing any previous such treaments for which they received coverage under a different insurance policy. This form can be found on the website maintained by the government of Connecticut.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 1: Enter the name of the individual seeking treatment on the first blank line, their date of birth on the second blank line, and their Social Security number on the third blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 2: Indicate whether you are covered as insured or as a dependent with a check mark.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 3: Enter the name of the insured on the fourth blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 4: Enter the current insurance carrier on the fifth blank line and your policy or ID number on the sixth blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 5: Indicate whether this is an individual or group plan with a check mark.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 6: If applicable, etner the group name on the seventh blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 7: Enter the date on which you began to be insured by the policy.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 8: If you have a secondary carrier, enter all information requested about them at the bottom of the first page.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 9: The first section of the second page concerns your previous carrier. Enter their name on the first blank line and the policy or identification number on the second blank line.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 10: Provide the name of the insured, the group number (if applicable) and the beginning and ending dates of coverage. Indicate with a check mark whether the insured was covered as insured or as a dependent, whether this was an individual or group plan, and if this was a fully insured or self insured plan.

Connecticut Infertility Treatment And Procedures Disclosure Form Step 11: Document previous treatment as instructed on the third page, then sign and date the bottom of the second page as instructed.

INSTRUCTIONS: ALABAMA COBRA EMPLOYER NOTICE MEMO (Form IB11)

Alabama state employers notify the State Employees' Insurance Board of various changes in the status of an employee under the provisions of COBRA who is enrolled in SEHIP by filing form IB11. This document can be obtained from the website maintained by the Alabama State Employee's Insurance Board. Alternately, you may choose to file form 11 to notify the State Employees' Insurance Board of these changes in status.

Alabama COBRA Employer Notice Memo IB11 Step 1: Enter the name of the employee on the first blank line.

Alabama COBRA Employer Notice Memo IB11 Step 2: Enter the social Security number of the employee on the second blank line.

Alabama COBRA Employer Notice Memo IB11 Step 3: Enter the street number or P.O. box number of the employee on the third blank line.

Alabama COBRA Employer Notice Memo IB11 Step 4: Enter the employee's city, state and zip code on the fourth blank line.

Alabama COBRA Employer Notice Memo IB11 Step 5: Enter the name of the employer on the fifth blank line.

Alabama COBRA Employer Notice Memo IB11 Step 6: Place a check mark on line 1 if the employee has been terminated for any reason other than gross misconduct. Enter the date of their termination.

Alabama COBRA Employer Notice Memo IB11 Step 7: Place a check mark on line 2 if the employee has had a reduction in the hours of employment, including taking leave without pay. Enter the date of this reduction.

Alabama COBRA Employer Notice Memo IB11 Step 8: Place a check mark on line 3 if the employee has died. Enter the date of death.

Alabama COBRA Employer Notice Memo IB11 Step 9: Place a check mark on line 4 if the employee has become eligible for Medicare. Enter the date on which they became eligible.

Alabama COBRA Employer Notice Memo IB11 Step 10: Enter the date on the next blank line.

Alabama COBRA Employer Notice Memo IB11 Step 11: The employer should enter their signature on the next blank line.

Alabama COBRA Employer Notice Memo IB11 Step 12: File the form by mailing it to the address given at the bottom of the page. Further assistance in completing this form can also be obtained by calling the phone numbers given here.

INSTRUCTIONS: ALABAMA MEDICATION REQUEST FORM (MRF)

Participating physicians and providers treating an Alabama public employee and obtaining coverage for a Prior Authorization drug for which there is no available suitable alternative use the medication request form discussed in this article. This website can be found on the website maintained by the Retirement Systems of Alabama.

Alabama Medication Request Form (MRF) Step 1: Enter the patient name in the first blank box.

Alabama Medication Request Form (MRF) Step 2: Enter the patient insurance company and contract number in the second blank box.

Alabama Medication Request Form (MRF) Step 3: Enter the patient date of birth in the third blank box.

Alabama Medication Request Form (MRF) Step 4: Enter the diagnosis in the fourth blank box.

Alabama Medication Request Form (MRF) Step 5: Enter the physician's name and their specialty in the fifth blank box.

Alabama Medication Request Form (MRF) Step 6: Enter the physician's telephone number in the sixth blank box.

Alabama Medication Request Form (MRF) Step 7: Enter the physician's DEA number in the seventh blank box.

Alabama Medication Request Form (MRF) Step 8: Enter the physician's fax number in the eighth blank box.

Alabama Medication Request Form (MRF) Step 9: Enter the pharmacy used by the patient in the ninth blank box.

Alabama Medication Request Form (MRF) Step 10: Enter the pharmacy telephone number in the tenth blank box.

Alabama Medication Request Form (MRF) Step 11: Enter the drug requested in the eleventh blank box.

Alabama Medication Request Form (MRF) Step 12: Enter the quantity per month in the twelfth blank box.

Alabama Medication Request Form (MRF) Step 13: Enter the dose in the thirteenth blank box.

Alabama Medication Request Form (MRF) Step 14: Enter the length of treatment in the fourteenth blank box.

Alabama Medication Request Form (MRF) Step 15: Enter the drug strength in the fifteenth blank box.

Alabama Medication Request Form (MRF) Step 16: Enter the dosage form in the sixteenth blank box.

Alabama Medication Request Form (MRF) Step 17: Enter the reason for the medication request in the seventeenth blank box.

Alabama Medication Request Form (MRF) Step 18: Enter other medications tried and/or failed where indicated, as well as other pertinent history bearing on your request.

Alabama Medication Request Form (MRF) Step 19: Fax the form to the number at the top of the page.

INSTRUCTIONS: ARIZONA APPLICATION FOR BINGO LICENSE (Form 71-1010)

To apply for an Arizona bingo license, file a form 71-1010. This document can be obtained from the website of the Arizona Department of Revenue.

Arizona Application For Bingo License 71-1010 Step 1: In boxes 1 through 4b, enter your name, telephone number, administrative office location and mailing address.

Arizona Application For Bingo License 71-1010 Step 2: Lines 5 through 11 should only be completed with check marks by Class B and Class C license applicants.

Arizona Application For Bingo License 71-1010 Step 3: On line 12, give the name, title and address of one or two persons who will serve as managers.

Arizona Application For Bingo License 71-1010 Step 4: On line 13, give the name, title and address of the person designated as proceeds coordinator.

Arizona Application For Bingo License 71-1010 Step 5: On line 14, enter the names, titles and address of up to four people who will serve as supervisors.

Arizona Application For Bingo License 71-1010 Step 6: On line 15, enter the names of up to eight people who will serve as assistants.

Arizona Application For Bingo License 71-1010 Step 7: On line 16, give the street address of the physical location where bingo will be played.

Arizona Application For Bingo License 71-1010 Step 8: On line 17, enter the hours during which bingo will be played on each line.

Arizona Application For Bingo License 71-1010 Step 9: On line 18, list the dates of proposed game cancellation, if any.

Arizona Application For Bingo License 71-1010 Step 10: On line 19, provide all information requested about the type of premises where bingo will be played.

Arizona Application For Bingo License 71-1010 Step 11: On line 20, list up to two bingo licensees who are or will be conducting bingo in the same premises as you or those who are located within 1,000 feet of your premises.

Arizona Application For Bingo License 71-1010 Step 12: In section 21, document your expected bingo expenses as instructed.

Arizona Application For Bingo License 71-1010 Step 13: In section 22, briefly state the specific projected use of net proceeds from games of bingo.

Arizona Application For Bingo License 71-1010 Step 14: In the last section, print your name, enter your signature, the date and your title.