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HMO Forms and HMO Form Filings - Life, Accident, and Health

HMO Forms and HMO Form Filings - Life, Accident, and Health
TDI Form Number Description File FormatLanguage
HMO001
Consumer Choice Evidence of Coverage (EOC) Checklist - Individual Plans
PDF English
HMO002
Consumer Choice Evidence of Coverage (EOC) Checklist - Large Employer and Conversion Plans
PDF English
HMO003
Consumer Choice Evidence of Coverage (EOC) Checklist - Small Employer and Conversion Plans
PDF English
HMO004
Evidence of Coverage (EOC) Checklist - Individual Plans
PDF English
HMO005
Evidence of Coverage (EOC) Checklist - Large Employer and Conversion Plans
PDF English
HMO006
Evidence of Coverage (EOC) Checklist - Small Employer and Conversion Plans
PDF English
HMO007
Evidence of Coverage (EOC) Checklist - Single Health Care Service Plan - Dental Care
PDF English
HMO008
Evidence of Coverage (EOC) Checklist - Single Health Care Service Plan - Vision Care
PDF English
LAHR344
HMO Reconciliation of Benefits to Schedule of Charges
PDF English
LHL610
Consumer Choice Health Benefit Plans Data Certification
PDF English
NOFR001
Prior Authorization of Health Care Services
PDF English
NOFR002
Prior Authorization of Prescription Drugs
PDF English

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