INSTRUCTIONS: ALABAMA APPLICATION FOR LICENSURE OF PHYSICIAN ASSISTANT

As part of the application to be licensed as a physician assistant in Alabama, the form discussed in this article should be filed. This document can be obtained from the website maintained by the Alabama Board of Medical Examiners.

Alabama Application For Licensure Of Physician Assistant Step 1: Section I concerns identifying information. Enter your name in full on the first blank line.

Alabama Application For Licensure Of Physician Assistant Step 2: Enter your home street address on the second blank line.

Alabama Application For Licensure Of Physician Assistant Step 3: Enter your city on the third blank line.

Alabama Application For Licensure Of Physician Assistant Step 4: Enter your state on the fourth blank line.

Alabama Application For Licensure Of Physician Assistant Step 5: Enter your zip code on the fifth blank line.

Alabama Application For Licensure Of Physician Assistant Step 6: Enter your place of birth on the sixth blank line.

Alabama Application For Licensure Of Physician Assistant Step 7: Enter your date of birth on the seventh blank line.

Alabama Application For Licensure Of Physician Assistant Step 8: Enter your sex on the eighth blank line.

Alabama Application For Licensure Of Physician Assistant Step 9: Enter your Social Security number on the ninth blank line.

Alabama Application For Licensure Of Physician Assistant Step 10: Enter your home telephone number, including the area code, on the tenth blank line.

Alabama Application For Licensure Of Physician Assistant Step 11: Section II contains 20 questions that must be answered by checking "Yes" or "No" as appropriate. If you answer "Yes" to any of them, you must attach a detailed explanation or the document requested.

Alabama Application For Licensure Of Physician Assistant Step 12: Section III requires you to document your education since graduating from high school. Enter the beginning and ending dates of your attendance in the first column, the name of each school in the second column, and the school's address in the third column.

Alabama Application For Licensure Of Physician Assistant Step 13: Section IV requires you to document your work activities since graduating from high school.

Alabama Application For Licensure Of Physician Assistant Step 14: In section V, list all places you have been certified, registered or licensed as a physician assistant. Sign and date Section VI before a notary public.

INSTRUCTIONS: PATIENT APPROVAL FORMS ALABAMA DENTAL HYGIENE LICENSURE EXAM

As part of the Alabama dental hygiene licensing process, exams are conducted in which patients agree to receive free treatment and assume the attendant risks. This article discusses the patient release forms which must be signed as part of this process. This packet can be obtained from the website maintained by the Alabama Board of Dental Examiners.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 1: The first page is a cover page.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 2: The second page is a release form. On the first blank line, the patient will enter their signature.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 3: On the second blank line, the patient will enter their date of birth.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 4: On the third blank line, the patient will enter the candidate identification number.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 5: On the fourth blank line, if the patient is a minor, their parent or guardian will enter their signature.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 6: On the fifth blank line, the patient or their parent or guardian will print their name.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 7: On the sixth blank line, the patient or their parent or guardian will enter their street address.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 8: On the seventh blank line, the patient or their parent or guardian will enter their city.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 9: On the eighth blank line, the patient or their parent or guardian will enter their state.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 10: On the ninth blank line, the patient or their parent or guardian will enter their zip code.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 11: The third page requires the signature and identification information of a witness.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 12: The fourth page is an information document.

Patient Approval Forms Alabama Dental Hygiene Licensure Exam Step 13: The remainder of the form contains a patient health history form, a radiographic statement and a periodontal history/treatment plan.

INSTRUCTIONS: ALABAMA NOTICE OF COVERAGE (WC Form 8)

Businesses operating in Alabama use WC form 8 to notify the state Department of Labor that they have worker's compensation insurance as required by law. This document can be obtained from the website maintained by the Alabama Department of Labor.

Alabama Notice Of Coverage WC 8 Step 1: Enter your state unemployment compensation tax number on the first blank line.

Alabama Notice Of Coverage WC 8 Step 2: Enter your federal ID number on the second blank line.

Alabama Notice Of Coverage WC 8 Step 3: Enter the name of your corporation or limited liability corporation (LLC) on the third blank line.

Alabama Notice Of Coverage WC 8 Step 4: Enter your "doing business as" (dba) business name on the fourth blank line.

Alabama Notice Of Coverage WC 8 Step 5: Enter the address of your primary location on the fifth blank line.

Alabama Notice Of Coverage WC 8 Step 6: Enter any additional locations covered by the worker's compensation insurance being documented on the sixth blank line.

Alabama Notice Of Coverage WC 8 Step 7: Enter the nature of your business on the seventh blank line.

Alabama Notice Of Coverage WC 8 Step 8: Enter your NAICS code number on the eighth blank line.

Alabama Notice Of Coverage WC 8 Step 9: Enter the effective date of the worker's compensation insurance policy on the ninth blank line.

Alabama Notice Of Coverage WC 8 Step 10: Enter the expiration date of the worker's compensation insurance policy on the tenth blank line.

Alabama Notice Of Coverage WC 8 Step 11: Enter the policy number of the worker's compensation insurance on the eleventh blank line.

Alabama Notice Of Coverage WC 8 Step 12: Enter the insurance carrier of the worker's compensation on the twelfth blank line.

Alabama Notice Of Coverage WC 8 Step 13: Enter the NCCI code of the insurance carrier on the thirteenth blank line.

Alabama Notice Of Coverage WC 8 Step 14: Mail the form to the address given at the top of the page.

Alabama Notice Of Coverage WC 8 Step 15: If you decide to cancel your worker's compensation insurance at a later time, this must also be documented with the Alabama Department of Labor. This is done by filing a form WC 9, which can also be obtained from their website.

INSTRUCTIONS: ARIZONA FINANCIAL REPORT FOR BINGO LICENSE CLASS "B" OR CLASS "C" (Form 71-1001)

During the process of applying for a bingo "B" or "C" class license in Arizona, a financial report must be filed. This document, form 71-1001, can be obtained from the website of the Arizona Department of Revenue.

Arizona Financial Report For Bingo License Class "B" Or Class "C" 71-1001 Step 1: Enter the beginning and ending dates of your reporting period.

Arizona Financial Report For Bingo License Class "B" Or Class "C" 71-1001 Step 2: Enter the licensee's name and address, license number, the number of occasions, the number of patrons and the phone number including the area code. Indicate the license classification with a check mark.

Arizona Financial Report For Bingo License Class "B" Or Class "C" 71-1001 Step 3: Lines 1 through 10 concern gross receipts. Enter admissions charges and card sales on line 1, special bonus game sales on line 2, sales of bingo supplies on line 3, interest from checking or savings accounts on line 4, and cash over on line 5.

Arizona Financial Report For Bingo License Class "B" Or Class "C" 71-1001 Step 4: Document NSF checks on line 6.

Arizona Financial Report For Bingo License Class "B" Or Class "C" 71-1001 Step 5: Enter the sum of lines 1, 2, 3, 4, 5 and 6D on line 7.

Arizona Financial Report For Bingo License Class "B" Or Class "C" 71-1001 Step 6: Skip to the second page and complete lines 16 through 18, which concern expenditures.

Arizona Financial Report For Bingo License Class "B" Or Class "C" 71-1001 Step 7: Transfer the value from line 18 on the second page to line 8 on the first page.

Arizona Financial Report For Bingo License Class "B" Or Class "C" 71-1001 Step 8: Subtract line 8 from line 7 and enter the resulting difference on line 9.

Arizona Financial Report For Bingo License Class "B" Or Class "C" 71-1001 Step 9: Complete Schedule I on the fourth page, then transfer the value from line 33 there to line 10 on the first page.

Arizona Financial Report For Bingo License Class "B" Or Class "C" 71-1001 Step 10: Subtract line 10 from line 9. Enter the resulting difference on line 11. Complete the remainder of the form as instructed.

INSTRUCTIONS: CONNECTICUT INSURANCE PREMIUM FINANCE COMPANY LICENSURE APPLICATION

To apply for a license to act as an insurance premium finance company in Connecticut, file the application discussed in this article. This document can be obtained from the website maintained by the government of the state of Connecticut as part of a packet which includes additional power of attorney forms that will need to be completed.

Connecticut Insurance Premium Finance Company Licensure Application Step 1: On line 1, state whether the applicant is an individual, partnership, association or corporation.

Connecticut Insurance Premium Finance Company Licensure Application Step 2: On line 2, enter the name of the applicant.

Connecticut Insurance Premium Finance Company Licensure Application Step 3: On line 2a, enter the federal employer identification number of the applicant.

Connecticut Insurance Premium Finance Company Licensure Application Step 4: On line 3, enter the street address, city or town, state and zip code of the principal office.

Connecticut Insurance Premium Finance Company Licensure Application Step 5: On line 4, enter the street address, city or town, state and zip code of up to two Connecticut branch offices.

Connecticut Insurance Premium Finance Company Licensure Application Step 6: On line 5, write what other business is or will be conducted at principal or branch offices.

Connecticut Insurance Premium Finance Company Licensure Application Step 7: If the applicant is a corporation or LLC, enter the place and date of incorporation on line 6.

Connecticut Insurance Premium Finance Company Licensure Application Step 8: If the applicant is a partnership, association or corporation, enter the names, title, business and home addresses and occupation of all partners, members or officers on line 7.

Connecticut Insurance Premium Finance Company Licensure Application Step 9: If the applicant is a corporation, enter the names, home and business addresses and occupation of all directors on line 8.

Connecticut Insurance Premium Finance Company Licensure Application Step 10: Lines 9 and 10 contain instructions for mandatory attachments.

Connecticut Insurance Premium Finance Company Licensure Application Step 11: Document your assets, liabilities and surplus on line 11.

Connecticut Insurance Premium Finance Company Licensure Application Step 12: Document each individual applicant as instructed on lines 12A through 12H.

Connecticut Insurance Premium Finance Company Licensure Application Step 13: Line 13 should be completed by corporations only.

Connecticut Insurance Premium Finance Company Licensure Application Step 14: Sign and date line 14.

INSTRUCTIONS: CONNECTICUT 2012 CONSUMER REPORT CARD SURVEY – PART 2

Managed care organizations are required to complete an annual consumer report card survey. This article discusses part 2 of this survey, which can be obtained from the website maintained by the government of Connecticut.

Connecticut 2012 Consumer Report Card Survey – Part 2 Step 1: On the first page, enter the name and address of the managed care organization, as well as the name and title of a contact person, and a contact telephone number and email address. You should also enter the number of primary care physicians in the provider network who are board certified where indicated.

Connecticut 2012 Consumer Report Card Survey – Part 2 Step 2: The second page concerns the percentage of physician specialists in the provider network who are board certified, breast cancer screenings, cervical cancer screenings, colorectal cancer screenings and controlling high blood pressure.

Connecticut 2012 Consumer Report Card Survey – Part 2 Step 3: The third page concerns cholesterol management for patients with cardiovascular conditions, childhood immunizations and beta blocker treatment after a heart attack.

Connecticut 2012 Consumer Report Card Survey – Part 2 Step 4: The fourth page concerns prenatal care in the first trimester and postpartum, adult access to preventive/ambulatory health services, outpatient drug utilization for managed care enrollees, and eye exams for people with diabetes.

Connecticut 2012 Consumer Report Card Survey – Part 2 Step 5: The fifth page concerns comprehensive diabetes care and member satisfaction.

Connecticut 2012 Consumer Report Card Survey – Part 2 Step 6: The next three pages contain questions which are to be answered by those enrolled in the network to measure member satisfaction.

Connecticut 2012 Consumer Report Card Survey – Part 2 Step 7: The ninth page is the beginning of the mental health services addendum. The ninth page concerns mental health utilization-inpatient discharges and average length of stays, mental health utilization percentage by level of care, and chemical dependency utilization inpatient discharges and length of stays.

Connecticut 2012 Consumer Report Card Survey – Part 2 Step 8: The next two pages require further information about mental health services.

Connecticut 2012 Consumer Report Card Survey – Part 2 Step 9: The twelfth page concerns fully insured and self insured behavioral health statistics, while the last page concerns claim denial data for the year.

INSTRUCTIONS: CONNECTICUT SHORT FORM CAMPAIGN FINANCE DISCLOSURE STATEMENT (SEEC Form 21)

A short form campaign finance disclosure statement can be submitted if a Connecticut committee did not receive contributions or funds or make or incur expenditures in excess of $1,000 for the period being documented. This is done using a SEEC form 21. This document can be obtained from the website of the government of Connecticut.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 1: On line 1, enter the name of the committee.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 2: In the first box on line 2, enter the title of the treasurer.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 3: In the second box, enter the treasurer's first name.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 4: In the third box, enter the treasurer's middle initial.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 5: In the fourth box, enter the treasurer's last name.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 6: In the fifth box, enter the treasurer's suffix, if applicable.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 7: On line 3, enter the treasurer's address.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 8: On line 4, enter the date of the election or referendum.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 9: On line 5, enter the office sought.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 10: On line 6, enter the district number, if applicable.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 11: On line 7, enter the candidate's name.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 12: On line 8, indicate what type of report is being filed by checking the appropriate box.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 13: On line 9, enter the beginning and ending dates of the period being covered.

Connecticut Short Form Campaign Finance Disclosure Statement SEEC Form 21 Step 14: On line 10, the treasurer or deputy treasurer should sign and print their name, as well as entering the date.

INSTRUCTIONS: CONNECTICUT PROPERTY EXECUTION PROCEEDINGS CLAIM FOR DETERMINATION OF INTERESTS IN DISPUTED PROPERTY (Form JD-CV-5C)

During a Connecticut case involving foreclosure or related procedures, a form JD-CV-5C is used to request a hearing concerning a party's claimed interests in disputed property. This document can be obtained from the website of the Connecticut Judicial Department.

Connecticut Property Execution Proceedings Claim For Determination Of Interests In Disputed Property JD-CV-5C Step 1: Enter the case docket number in the first blank box.

Connecticut Property Execution Proceedings Claim For Determination Of Interests In Disputed Property JD-CV-5C Step 2: In the second blank box, indicate whether the case is in judicial district court, housing session court, a small claims area (enter its location), or a geographical area (enter its number).

Connecticut Property Execution Proceedings Claim For Determination Of Interests In Disputed Property JD-CV-5C Step 3: In the third blank box, enter the date of judgment.

Connecticut Property Execution Proceedings Claim For Determination Of Interests In Disputed Property JD-CV-5C Step 4: In the fourth blank box, enter the address of the court.

Connecticut Property Execution Proceedings Claim For Determination Of Interests In Disputed Property JD-CV-5C Step 5: In the fifth blank box, enter the original case caption.

Connecticut Property Execution Proceedings Claim For Determination Of Interests In Disputed Property JD-CV-5C Step 6: In the sixth blank box, enter the date of service of execution or application for turnover order.

Connecticut Property Execution Proceedings Claim For Determination Of Interests In Disputed Property JD-CV-5C Step 7: In the next two blank boxes, enter the names and addresses of the judgment creditors and debtors, respectively.

Connecticut Property Execution Proceedings Claim For Determination Of Interests In Disputed Property JD-CV-5C Step 8: In the next two blank boxes, enter the names and addresses of persons claiming an interest in the property and a description of the applicable property.

Connecticut Property Execution Proceedings Claim For Determination Of Interests In Disputed Property JD-CV-5C Step 9: In the next blank box, state the basis of your claim, superior interest or the nature of the dispute.

Connecticut Property Execution Proceedings Claim For Determination Of Interests In Disputed Property JD-CV-5C Step 10: Sign, date and print your name in the next three blank boxes.

Connecticut Property Execution Proceedings Claim For Determination Of Interests In Disputed Property JD-CV-5C Step 11: Complete the remainder of the form as directed.