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Preferred Provider Network License Application

Preferred Provider Network License Application

 

INSTRUCTIONS: CONNECTICUT PREFERRED PROVIDER NETWORK (PPN) LICENSE INSTRUCTIONS AND APPLICATION (INITIAL)

 

 

To apply for an initial license to act as a Connecticut preferred provider network (PPN), use the form discussed in this article. This document can be obtained from the website maintained by the government of Connecticut.

 

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Initial) Step 1: The first page contains general instructions for completion.

 

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Initial) Step 2: On the first five blank lines of the second page, enter the PPN name, its tax identification number or federal employer identification number, its business address, its mailing address (if different) and its phone number.

 

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Initial) Step 3: The next six lines concern contact information to be used by the state Insurance Department for all future correspondence. Enter the name and title of a contact person, their mailing address, their phone number, their fax number and their email address.

 

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Initial) Step 4: Indicate whether your company provides services for workers compensation only by filling in the oval next to "Yes" or "No." If yes, you do not need to complete the remainder of the application and may skip to the CEO certification on page 7.

 

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Initial) Step 5: Indicate whether your organization is registered with the Insurance Department as a Pharmacy Benefit Manager by filling in the oval next to "Yes" or "No." If yes, you do not need to complete the remainder of the application and may skip to the CEO certification on page 7.

 

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Initial) Step 6: Enter the name and a description of your controlling company or organization.

 

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Initial) Step 7: Enter a contact name for your controlling company and organization, as well as their business and mailing addresses.

 

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Initial) Step 8: Enter the name of your related or predecessor controlling company or organization and its address at the top of the third page.

 

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Initial) Step 9: Complete the rest of the form as instructed.

 

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