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79
![Form HIPMC-F1 "Face Sheet and Verification Form" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22648/2264845/form-hipmc-f1-face-sheet-and-verification-form-kentucky.png "Form HIPMC-F1 "Face Sheet and Verification Form" - Kentucky")
![Form HIPMC-MD-1 "Medical Director Report Form" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22648/2264854/form-hipmc-md-1-medical-director-report-form-kentucky.png "Form HIPMC-MD-1 "Medical Director Report Form" - Kentucky")
![Form HIPMC-IRE-3 "External Review Decision Notification Form" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264936/form-hipmc-ire-3-external-review-decision-notification-form-kentucky.png "Form HIPMC-IRE-3 "External Review Decision Notification Form" - Kentucky")
![Form HIPMC-IRE-6 "External Review Information Face Sheet" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264934/form-hipmc-ire-6-external-review-information-face-sheet-kentucky.png "Form HIPMC-IRE-6 "External Review Information Face Sheet" - Kentucky")
![Form HIPMC-IRE-2 "Assignment of Independent Review Entity Form" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264938/form-hipmc-ire-2-assignment-of-independent-review-entity-form-kentucky.png "Form HIPMC-IRE-2 "Assignment of Independent Review Entity Form" - Kentucky")
![Form HIPMC-IRE-4 "Annual Independent Review Entity Report Form" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264939/form-hipmc-ire-4-annual-independent-review-entity-report-form-kentucky.png "Form HIPMC-IRE-4 "Annual Independent Review Entity Report Form" - Kentucky")
![Form HIPMC-IRE-1 "Application for Certification of an Independent Review Entity" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264937/form-hipmc-ire-1-application-for-certification-of-an-independent-review-entity-kentucky.png "Form HIPMC-IRE-1 "Application for Certification of an Independent Review Entity" - Kentucky")
![Form HIPMC-UR-1 "Utilization Review Registration Application Instruction" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22648/2264860/form-hipmc-ur-1-utilization-review-registration-application-instruction-kentucky.png "Form HIPMC-UR-1 "Utilization Review Registration Application Instruction" - Kentucky")
Form HIPMC-UR-1 "Utilization Review Registration Application Instruction" - Kentucky
Size: 173 KB
7 pages
![Form HIPMC-UR-2 "Annual Utilization Review (Ur) Report Form" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22648/2264858/form-hipmc-ur-2-annual-utilization-review-ur-report-form-kentucky.png "Form HIPMC-UR-2 "Annual Utilization Review (Ur) Report Form" - Kentucky")
![Form HIPMC-R4 "Individual Health Forms - Actuarial Certification Form" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264925/form-hipmc-r4-individual-health-forms-actuarial-certification-form-kentucky.png "Form HIPMC-R4 "Individual Health Forms - Actuarial Certification Form" - Kentucky")
![Form HL-MS-1 "Medicare Supplement Refund Calculation Form" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264933/form-hl-ms-1-medicare-supplement-refund-calculation-form-kentucky.png "Form HL-MS-1 "Medicare Supplement Refund Calculation Form" - Kentucky")
![Form LS6 "Life Settlement Provider Certification Form" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264927/form-ls6-life-settlement-provider-certification-form-kentucky.png "Form LS6 "Life Settlement Provider Certification Form" - Kentucky")
![Form HIPMC-IPO-4 "Quarterly Financial Statement of Insurance Purchasing Outlet" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264940/form-hipmc-ipo-4-quarterly-financial-statement-of-insurance-purchasing-outlet-kentucky.png "Form HIPMC-IPO-4 "Quarterly Financial Statement of Insurance Purchasing Outlet" - Kentucky")
![Form MLW-01 "Request for Waiver of Renewal Procedures or Exemption From Examination or Extension for Continuing Education Due to Active Military Service Deployment" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264903/form-mlw-01-request-for-waiver-of-renewal-procedures-or-exemption-from-examination-or-extension-for-continuing-education-due-to-active-military-service-deployment-kentucky.png "Form MLW-01 "Request for Waiver of Renewal Procedures or Exemption From Examination or Extension for Continuing Education Due to Active Military Service Deployment" - Kentucky")
![Form KYP-01 "Provider Approval Application - Continuing Education/Pre-licensing Program" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264906/form-kyp-01-provider-approval-application-continuing-education-pre-licensing-program-kentucky.png "Form KYP-01 "Provider Approval Application - Continuing Education/Pre-licensing Program" - Kentucky")
![Form HIPMC-R36 "Rate Filing Information Form (Limited Benefits)" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264929/form-hipmc-r36-rate-filing-information-form-limited-benefits-kentucky.png "Form HIPMC-R36 "Rate Filing Information Form (Limited Benefits)" - Kentucky")
![Form HL-F11 "Health Summary Sheet - Form Filings" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264930/form-hl-f11-health-summary-sheet-form-filings-kentucky.png "Form HL-F11 "Health Summary Sheet - Form Filings" - Kentucky")
![Form HIPMC-F16 "Additional Health Information Request Form" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264928/form-hipmc-f16-additional-health-information-request-form-kentucky.png "Form HIPMC-F16 "Additional Health Information Request Form" - Kentucky")
![Form CPL-01 "Certificate of Pre-licensing Course Completion" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264907/form-cpl-01-certificate-of-pre-licensing-course-completion-kentucky.png "Form CPL-01 "Certificate of Pre-licensing Course Completion" - Kentucky")
![Form 440 "Certificate on Advertising - Accident and Health" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22648/2264838/form-440-certificate-on-advertising-accident-and-health-kentucky.png "Form 440 "Certificate on Advertising - Accident and Health" - Kentucky")
![Form CE/AFF-304 "Affidavit for Exemption From Continuing Education" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264912/form-ce-aff-304-affidavit-for-exemption-from-continuing-education-kentucky.png "Form CE/AFF-304 "Affidavit for Exemption From Continuing Education" - Kentucky")
![Form PBM "Pharmacy Benefit Manager License Application" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264910/form-pbm-pharmacy-benefit-manager-license-application-kentucky.png "Form PBM "Pharmacy Benefit Manager License Application" - Kentucky")
![Form 145 "Transaction Sheet for Securities Held Under Safekeeping With Designated Custodian Banks" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264953/form-145-transaction-sheet-for-securities-held-under-safekeeping-with-designated-custodian-banks-kentucky.png "Form 145 "Transaction Sheet for Securities Held Under Safekeeping With Designated Custodian Banks" - Kentucky")
![Form 100 "Initial Application for Certificate of Filing as a Workers' Compensation Self-insured Group" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264958/form-100-initial-application-for-certificate-of-filing-as-a-workers-compensation-self-insured-group-kentucky.png "Form 100 "Initial Application for Certificate of Filing as a Workers' Compensation Self-insured Group" - Kentucky")
![Form 102 "Trustee Confirmation of Receipt Workers' Compensation Self-insured Group Quarterly Financial Statements" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264954/form-102-trustee-confirmation-of-receipt-workers-compensation-self-insured-group-quarterly-financial-statements-kentucky.png "Form 102 "Trustee Confirmation of Receipt Workers' Compensation Self-insured Group Quarterly Financial Statements" - Kentucky")
![Form 141 "Workers' Compensation Self-insured Groups Election Form for Safekeeping of Securities" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264951/form-141-workers-compensation-self-insured-groups-election-form-for-safekeeping-of-securities-kentucky.png "Form 141 "Workers' Compensation Self-insured Groups Election Form for Safekeeping of Securities" - Kentucky")
![Form 995 "Application for Certificate of Filing as a Liability Self-insurance Group" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264941/form-995-application-for-certificate-of-filing-as-a-liability-self-insurance-group-kentucky.png "Form 995 "Application for Certificate of Filing as a Liability Self-insurance Group" - Kentucky")
![Form 142 "Letter of Credit" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264952/form-142-letter-of-credit-kentucky.png "Form 142 "Letter of Credit" - Kentucky")
![Form 147 "Workers' Compensation Group Security Deposit Held Under Safekeeping" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264955/form-147-workers-compensation-group-security-deposit-held-under-safekeeping-kentucky.png "Form 147 "Workers' Compensation Group Security Deposit Held Under Safekeeping" - Kentucky")
![Form CI110 "Application for Authorization to Certify Loss Reserves and Loss Expense Reserves for Captives" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264947/form-ci110-application-for-authorization-to-certify-loss-reserves-and-loss-expense-reserves-for-captives-kentucky.png "Form CI110 "Application for Authorization to Certify Loss Reserves and Loss Expense Reserves for Captives" - Kentucky")
![Form CI120 "Application for Authorization as an Independent Certified Public Accountant for Captive Insurance Business" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264950/form-ci120-application-for-authorization-as-an-independent-certified-public-accountant-for-captive-insurance-business-kentucky.png "Form CI120 "Application for Authorization as an Independent Certified Public Accountant for Captive Insurance Business" - Kentucky")
![Form CE/PL-100 "Course Approval Application - Continuing Education/Pre-licensing Program" - Kentucky](https://data.templateroller.com/pdf_docs_html/1861/18618/1861806/form-ce-pl-100-course-approval-application-continuing-education-pre-licensing-program-kentucky.png "Form CE/PL-100 "Course Approval Application - Continuing Education/Pre-licensing Program" - Kentucky")
![Form 800 "Kentucky Designation of Person to Receive Legal Process" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22648/2264834/form-800-kentucky-designation-of-person-to-receive-legal-process-kentucky.png "Form 800 "Kentucky Designation of Person to Receive Legal Process" - Kentucky")
![Form CE/PL-200 "Instructor Approval Application - Continuing Education/Pre-licensing Program" - Kentucky](https://data.templateroller.com/pdf_docs_html/1861/18618/1861804/form-ce-pl-200-instructor-approval-application-continuing-education-pre-licensing-program-kentucky.png "Form CE/PL-200 "Instructor Approval Application - Continuing Education/Pre-licensing Program" - Kentucky")
![Form VOC "Verification of Coverage for Life Insurance Policies" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264972/form-voc-verification-of-coverage-for-life-insurance-policies-kentucky.png "Form VOC "Verification of Coverage for Life Insurance Policies" - Kentucky")
![Form LGT141 "City, County, or Urban County Government Quarterly Insurance Premium Tax Return" - Kentucky](https://data.templateroller.com/pdf_docs_html/2264/22649/2264900/form-lgt141-city-county-or-urban-county-government-quarterly-insurance-premium-tax-return-kentucky.png "Form LGT141 "City, County, or Urban County Government Quarterly Insurance Premium Tax Return" - Kentucky")
