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Sample Forms Listing

Sample Forms Listing
TDI Form Number Description File FormatLanguage
SN002
Notice to HMO Enrollees
PDF English
SN003
Workers Comp Network Sample Contingency Plan
PDF English
SN004
Workers Comp Net Sample Employee Acknowledgment Form
PDF English
SN005
Workers Comp Net Employee Acknowledgment Form
PDF Spanish
SN006
Workers Comp Net Sample Employee Acknowledgment Form - Chinese
PDF Chinese
SN007
Workers Comp Net Sample Employee Acknowledgment Form
PDF Vietnamese
SN008
Workers Comp Network Sample QI Report
PDF English
SN009
Sample URA Adverse Determination Notice, Health
PDF English
SN010
Sample URA Adverse Determination Notice, Specialty Health
PDF English
SN011
Sample URA Adverse Determination Notice, Workers Comp Net
PDF English
SN012
Sample URA Adverse Determination Notice, Workers Comp Non-Network
PDF English
SN014
Delegated Entity Data Form
Sample format for use by HMOs and WC HCNs when submitting delegation agreements to the Texas Department of Insurance
PDF English

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