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Managed Care Quality Assurance Other Forms

Managed Care Quality Assurance Other Forms
TDI Form Number Description File FormatLanguage
FIN306
Officers and Directors Page
Complete Listing of all Current Officers and Directors
PDF English
FIN542
HMO Delegation Agreement Checklist
PDF English
FIN543
Preferred Provider Benefit Plan and Exclusive Provider Benefit Plan Annual Network Adequacy Report and Access Plan Checklist
PDF English
FIN544
HMO Network Access Plan Requirements
PDF English
fin593
HMO/INSURER PROMPT PAY PENALTY REPORTING FORM
PDF English
FIN596
Provider Network Contracting Entity Registration and Exemption Form
PNCE Registration and Exemption Form
PDF English
FIN601
HEALTH MAINTEANCE ORGANIZATION ANNUAL NETWORK ADEQUACY REPORT & ACCESS PLAN CHECKLIST
PDF English
LHL658
Application for Approval of Exclusive Provider Benefit Plan (EPBP)
PDF English

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