2018 Public Health Fee Assessment Request - Connecticut
STATE OF CONNECTICUT
Public Health Fee Assessment Request
For Number of Insured or Enrolled Lives in CT as of May 1
Per Conn. Gen. Stat. Sec. 19a-7p
Report Due Date: September 1
City, State, Zip:
Note: All letters and email will be sent to this address. Email should be address used for
NUMBER OF INSURED OR ENROLLED LIVES IN CT:
Report Number: If none, please report as “NONE”
Not later than September 1
annually, each such insurer and health care center shall report to
the Insurance Commissioner... the number of insured or enrolled lives in this state as of the
preceding May 1
, for which such insurer or health care center is providing health insurance
coverage of the types specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469.
Do not include lives enrolled in Medicare, any medical assistance program administered by
the Department of Social Services, workers compensation insurance or Medicare Part C plans.
(Conn. Gen. Stats. Sec. 19a-7p).
PUBLIC HEALTH FEE ASSESSMENT FORM
Form PHS-6353-1 Public Health Service Commissioned Officer's State Tax Withholding Allowance Certificate
Form PHS-6379 Supplemental Medical History Record Required of Applicants to or Officers of the Public Health Service Commissioned Corps
Medicare Patient Health Risk Assessment (Hra) & History Form - Sccipa - Santa Clara County, California