"Application to Be a Qualified Vendor of Behavioral Health Clinical Review Criteria" - Connecticut

Application to Be a Qualified Vendor of Behavioral Health Clinical Review Criteria is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Application to be a Qualified Vendor of Behavioral
Health Clinical Review Criteria
Company Name
___________________________________________________________
Company Address
___________________________________________________________
___________________________________________________________
___________________________________________________________
Contact Name
___________________________________________________________
Contact phone number ____________________________________________________________
Contact e-mail address ____________________________________________________________
Please list companies licensed to write health insurance in Connecticut that currently utilize your
behavioral health clinical review criteria:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
www.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Application to be a Qualified Vendor of Behavioral
Health Clinical Review Criteria
Company Name
___________________________________________________________
Company Address
___________________________________________________________
___________________________________________________________
___________________________________________________________
Contact Name
___________________________________________________________
Contact phone number ____________________________________________________________
Contact e-mail address ____________________________________________________________
Please list companies licensed to write health insurance in Connecticut that currently utilize your
behavioral health clinical review criteria:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
www.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer
THE FOLLOWING CERTIFICATION MUST BE COMPLETED WHEN
APPLYING TO BE A QUALIFIED VENDOR FOR BEHAVIORAL HEALTH
CLINCIAL REVIEW CRITERIA
I, _________________________________________, _____________________________________
(PRINTED NAME)
(TITLE)
of _________________________________________________________, hereby acknowledge that
(COMPANY)
_____________________________________________________, meets the requirements to become a
(COMPANY)
qualified vendor for behavioral health clinical review criteria in accordance with Conn. Gen.
Stat.§§38a-591c and as outlined in Bulletin HC-105.
_____________________________
(SIGNATURE)
______________________________
(DATE)
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