INSTRUCTIONS: CONNECTICUT REQUEST FOR EXTERNAL REVIEW

A Connecticut patient who has been denied health insurance coverage for a procedure may request an external review from the state's Insurance Department by using the form discussed in this article. This document can be obtained from the website of the government of Connecticut.

Connecticut Request For External Review Step 1: The first section concerns the person who is requesting the external review. Enter your name on the first blank line.

Connecticut Request For External Review Step 2: Enter the applicant address on the second blank line.

Connecticut Request For External Review Step 3: Enter the applicant daytime phone number on the third blank line.

Connecticut Request For External Review Step 4: Enter the applicant email address on the fourth blank line.

Connecticut Request For External Review Step 5: Indicate with a check mark whether the applicant is the enrollee or patient, the parent of a minor child under 18, the provider, or a legal or authorized representative.

Connecticut Request For External Review Step 6: The second section concerns the enrollee or patient who had their request for medical care denied. Enter their name on the first blank line, their address on the second blank line and their phone number on the third blank line.

Connecticut Request For External Review Step 7: The third section concerns the insurance company. Enter the insurance company or health plan name on the first blank line, the subscriber name on the second blank line, the subscriber insurance identification number on the third blank line and the dependent insurance identification number on the fourth blank line.

Connecticut Request For External Review Step 8: Indicate whether the coverage is an individual plan, a group plan through an employer, or a group plan through a plan sponsor with a check mark.

Connecticut Request For External Review Step 9: The fourth section concerns the provider. Enter the name of the treating physician on the first blank line, their address on the second blank line, the name of a contact person on the third blank line, their email address on the fourth blank line, and their telephone number on the fifth blank line.

Connecticut Request For External Review Step 10: Provide an explanation for your appeal where indicated.

Connecticut Request For External Review Step 11: Complete the second page as instructed. The third and fourth pages should be completed by the physician.

INSTRUCTIONS: ALABAMA APPLICATION FOR REGISTRATION OF PHYSICIAN ASSISTANT 

To register a physician assistant in Alabama, use the application discussed in this article. This document can be obtained from the website maintained by the Alabama Board of Medical Examiners.

Alabama Application For Registration Of Physician Assistant Step 1: The first page should be completed by the physician. On the first blank line, the physician should enter their name in full.

Alabama Application For Registration Of Physician Assistant Step 2: On the second blank line, the physician should enter their Alabama medical license number.

Alabama Application For Registration Of Physician Assistant Step 3: On the third blank line, the physician should enter their date of birth.

Alabama Application For Registration Of Physician Assistant Step 4: On the fourth blank line, the physician should enter their Social Security number.

Alabama Application For Registration Of Physician Assistant Step 5: On the fifth blank line, the physician should enter their medical specialty.

Alabama Application For Registration Of Physician Assistant Step 6: The physician should indicate whether they are board certified or board eligible by circling "Yes" or "No" as appropriate.

Alabama Application For Registration Of Physician Assistant Step 7: On the sixth blank line, the physician should enter their principal practice location address. If their mailing address is different, they should enter it on the seventh blank line.

Alabama Application For Registration Of Physician Assistant Step 8: On the eighth and and ninth blank line, the physician should enter their telephone and fax numbers.

Alabama Application For Registration Of Physician Assistant Step 9: In section 1, the physician should provide the name, practice site address and designated working hours per week of each physician assistant  and/or CRNP and/or CNM currently registered to them.

Alabama Application For Registration Of Physician Assistant Step 10: In section 2, the physician should indicate with a check mark whether they have ever had a physician assistant certified or registered to them by the Alabama Board of Medical Examiners. In section 3, the physician should indicate with a check mark whether the physician assistant for whom registration is sought is employed by them, their group, partnership or professional corporation. They should sign and date the bottom of the page.

Alabama Application For Registration Of Physician Assistant Step 11: Complete the second page as instructed.

INSTRUCTIONS: ALABAMA STATE EMPLOYEES' HEALTH INSURANCE PLAN WELLNESS DISCOUNT CERTIFICATION FORM (Form IB07)

Alabama state employees use form IB07 to obtain a wellness discount certification after participating in a worksite wellness screening and completing one of the requirements to reduce health risks. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 1: Print your name in the first blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 2: Indicate whether you are male or female with a check mark.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 3: Enter your age in the second blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 4: Enter your contract number in the third blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 5: Enter your Social Security number in the fourth blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 6: Enter your date of birth in the fifth blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 7: Enter your daytime phone number, including the area code, in the sixth blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 8: Check the first statement if you were counseled by your health care provider about the health risks identified in your wellness screening results and are attaching either a Wellness Program Office Visit Referral or a Completed Provider Screening Form. Indicate which with a check mark.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 9: Check the second statement if you participated in a Physician Supervised Weight Management program. Enter the name and phone number of the program and the dates you attended.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 10: Check the third statement if you participated in a SEIB fitness center's wellness program. Enter the name and phone number of the program, the dates you attended and a program description.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 11: Check the fourth statement if you are self-managing your health risks and attach valid proof.

INSTRUCTIONS: ALABAMA PEEHIP HEALTH INSURANCE AND OPTIONAL STATUS CHANGE 

Alabama public employees enrolled in the state-administered health insurance plan use the document discussed in this article to make an optional status change. This document can be obtained from the website maintained by the Retirement Systems of Alabama.

Alabama PEEHIP Health Insurance And Optional Status Change Step 1: Indicate whether you are an active or retired member with a check mark.

Alabama PEEHIP Health Insurance And Optional Status Change Step 2: The first section concerns the subscriber. On the first line, enter your Social Security number or PiD number, first name, middle name or initial and last name.

Alabama PEEHIP Health Insurance And Optional Status Change Step 3: On the second line, enter your date of birth and daytime phone number, as well as indicating your marital status with a check mark.

Alabama PEEHIP Health Insurance And Optional Status Change Step 4: On the third line, indicate with a check mark whether you or your spouse have used tobacco products in the last 12 months.

Alabama PEEHIP Health Insurance And Optional Status Change Step 5: In the next two blank boxes, if you have changed names, enter your previous full name and new full name.

Alabama PEEHIP Health Insurance And Optional Status Change Step 6: In the next blank box, if you have changed jobs, enter your date of employment transfer.

Alabama PEEHIP Health Insurance And Optional Status Change Step 7: In the next section, indicate the type of coverage change you wish to make by placing a check mark next to the applicable statement. Enter your requested effective date at the bottom of this section.

Alabama PEEHIP Health Insurance And Optional Status Change Step 8: In the next section, indicate the reasons for these changes by checking all applicable statements.

Alabama PEEHIP Health Insurance And Optional Status Change Step 9: The next section concerns dependents and is only required for family coverage.

Alabama PEEHIP Health Insurance And Optional Status Change Step 10: The next section at the top of the second page must be completed if the member elects the PEEHIP supplemental plan or if the member or their dependents have other group health, dental or vision coverage currently in effect.

Alabama PEEHIP Health Insurance And Optional Status Change Step 11: Provide all other information requested. Sign and date the bottom of the form.

INSTRUCTIONS: ARIZONA ENDORSEMENT BY LOCAL GOVERNING BODY (Form 71-1002)

As part of the Arizona bingo license application process, a form 71-1002 must be submitted documenting endorsement from your local governing body. This document can be obtained from the website of the Arizona Department of Revenue.

Arizona Endorsement By Local Governing Body 71-1002 Step 1: Indicate with a check mark if this is a new application or one documenting a change of location.

Arizona Endorsement By Local Governing Body 71-1002 Step 2: In the first two blank boxes, enter your license number and the date.

Arizona Endorsement By Local Governing Body 71-1002 Step 3: In the next blank box, enter the name of the local governing body.

Arizona Endorsement By Local Governing Body 71-1002 Step 4: In the next blank box, enter the street number or P.O. box of the local governing body.

Arizona Endorsement By Local Governing Body 71-1002 Step 5: In the next blank box, enter the telephone number of the local governing body.

Arizona Endorsement By Local Governing Body 71-1002 Step 6: In the next blank box, enter the city, state and zip code of the local governing body.

Arizona Endorsement By Local Governing Body 71-1002 Step 7: On line 1, enter the date on which your hearing was conducted.

Arizona Endorsement By Local Governing Body 71-1002 Step 8: Indicate with a check mark whether the hearing concerned a hearing for a bingo license or for a bingo license location transfer.

Arizona Endorsement By Local Governing Body 71-1002 Step 9: On line 2, enter the name of the applicant.

Arizona Endorsement By Local Governing Body 71-1002 Step 10: On line 3, enter the location or address where games will be conducted.

Arizona Endorsement By Local Governing Body 71-1002 Step 11: On line 4, enter the days and times on which games will be conducted.

Arizona Endorsement By Local Governing Body 71-1002 Step 12: On line 5, indicate with a check mark whether background investigations have been conducted on all individuals listed on the Bingo License Application.

Arizona Endorsement By Local Governing Body 71-1002 Step 13: On line 6, indicate with a check mark whether you recommend the application be approved or disapproved.

Arizona Endorsement By Local Governing Body 71-1002 Step 14: On line 7, enter any specific reasons you have for your recommendation. Sign and date the form where indicated.

INSTRUCTIONS: CONNECTICUT SURPLUS LINES AFFIDAVIT (Form SL-8)

To document Connecticut surplus lines, use a form SL-8. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut Surplus Lines Affidavit SL-8 Step 1: Enter the name and address of the surplus lines broker on line 1.

Connecticut Surplus Lines Affidavit SL-8 Step 2: Enter the name of the producing agency on line 2.

Connecticut Surplus Lines Affidavit SL-8 Step 3: Enter the Connecticut license number of the producing agency on line 2a.

Connecticut Surplus Lines Affidavit SL-8 Step 4: Enter the agency represented on line 3.

Connecticut Surplus Lines Affidavit SL-8 Step 5: Enter the Connecticut license number of the agency represented on line 3a.

Connecticut Surplus Lines Affidavit SL-8 Step 6: Enter the name and location on the risk on line 4.

Connecticut Surplus Lines Affidavit SL-8 Step 7: Enter surplus lines insurers and their NAIC number on lines 5a and 5b.

Connecticut Surplus Lines Affidavit SL-8 Step 8: Enter the name of the associated representative on line 5c.

Connecticut Surplus Lines Affidavit SL-8 Step 9: Enter the kind of insurance on line 6.

Connecticut Surplus Lines Affidavit SL-8 Step 10: Enter the limits on line 6a.

Connecticut Surplus Lines Affidavit SL-8 Step 11: Enter the risk description on line 6b.

Connecticut Surplus Lines Affidavit SL-8 Step 12: Indicate whether this is a new business policy or renewal on line 7 with a check mark.

Connecticut Surplus Lines Affidavit SL-8 Step 13: Enter the reasons for placement on line 7b.

Connecticut Surplus Lines Affidavit SL-8 Step 14: Enter the premium on line 8.

Connecticut Surplus Lines Affidavit SL-8 Step 15: Indicate whether this is a term premium, installment or subject to audit with a check mark on line 8a.

Connecticut Surplus Lines Affidavit SL-8 Step 16: Enter the policy period on line 8b.

Connecticut Surplus Lines Affidavit SL-8 Step 17: On line 9, indicate with a check mark whether the broker completing this form has on file evidence of declination by three licensed insurers and ineligibility for any residential market mechanism.

Connecticut Surplus Lines Affidavit SL-8 Step 18: Enter the broker service fee on line 9a and the producer service fee on line 9b.

Connecticut Surplus Lines Affidavit SL-8 Step 19: The insured should sign the form in the presence of a notary public.