Form FIN596 "Provider Network Contracting Entity Registration or Exemption of Affiliates Form" - Texas

What Is Form FIN596?

This is a legal form that was released by the Texas Department of Insurance - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2016;
  • The latest edition provided by the Texas Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form FIN596 by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form FIN596 "Provider Network Contracting Entity Registration or Exemption of Affiliates Form" - Texas

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FIN596 | 0216
PROVIDER NETWORK CONTRACTING ENTITY
REGISTRATION OR EXEMPTION OF AFFILIATES FORM
The applicant must provide the following information to the Texas Department
of Insurance at MCQA@tdi.texas.gov, or by mail to Managed Care Quality Assurance Office,
Financial Regulation Division, Mail Code 103-6A, Texas Department of Insurance, P.O. Box 149104,
Austin, Texas 78714-9104.
1. All names used or that will be used by the provider network contracting entity, including any name
under which the contracting entity intends to engage or has engaged in the business of insurance in Texas:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2. Provider network contracting entity’s mailing address:
_____________________________________________________________________________
_____________________________________________________________________________
3. Provider network contracting entity’s main telephone number:
(____)_______-_____________________
4. Provider network contracting entity’s primary contact name:
__________________________________
5. Provider network contracting entity’s primary contact telephone number:
(____)_______-_____________________
6. Disclose and clearly define the relationships between the applicant and all listed affiliates of the applicant, as
required under Texas Insurance Code § 1458.055 and 28 Texas Administrative Code § 3.9803, including primary
provider networks, subsidiary provider networks, and other provider networks as defined in § 3.9801.
(Add additional pages as necessary).
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
7. List each affiliate, and the affiliate’s address, for which an exemption is requested. (If applicable)
(Add additional pages as necessary):
___________________________________________________________________________
___________________________________________________________________________
If you have questions or require assistance regarding this form,
please call 512-676-6400, select Option 8.
NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES
With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collects about you.
Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself,
including private information. However, TDI may withhold information for reasons other than to protect your right to privacy. Under section
559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For
more information about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by
TDI, please contact the Agency Counsel Section of TDI’s General Counsel Division at (512) 676-6551 or visit the Corrections Procedure section of
TDI’s website at www.tdi.texas.gov.
Texas Department of Insurance | www.tdi.texas.gov
1/1
FIN596 | 0216
PROVIDER NETWORK CONTRACTING ENTITY
REGISTRATION OR EXEMPTION OF AFFILIATES FORM
The applicant must provide the following information to the Texas Department
of Insurance at MCQA@tdi.texas.gov, or by mail to Managed Care Quality Assurance Office,
Financial Regulation Division, Mail Code 103-6A, Texas Department of Insurance, P.O. Box 149104,
Austin, Texas 78714-9104.
1. All names used or that will be used by the provider network contracting entity, including any name
under which the contracting entity intends to engage or has engaged in the business of insurance in Texas:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2. Provider network contracting entity’s mailing address:
_____________________________________________________________________________
_____________________________________________________________________________
3. Provider network contracting entity’s main telephone number:
(____)_______-_____________________
4. Provider network contracting entity’s primary contact name:
__________________________________
5. Provider network contracting entity’s primary contact telephone number:
(____)_______-_____________________
6. Disclose and clearly define the relationships between the applicant and all listed affiliates of the applicant, as
required under Texas Insurance Code § 1458.055 and 28 Texas Administrative Code § 3.9803, including primary
provider networks, subsidiary provider networks, and other provider networks as defined in § 3.9801.
(Add additional pages as necessary).
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
7. List each affiliate, and the affiliate’s address, for which an exemption is requested. (If applicable)
(Add additional pages as necessary):
___________________________________________________________________________
___________________________________________________________________________
If you have questions or require assistance regarding this form,
please call 512-676-6400, select Option 8.
NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES
With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collects about you.
Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself,
including private information. However, TDI may withhold information for reasons other than to protect your right to privacy. Under section
559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For
more information about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by
TDI, please contact the Agency Counsel Section of TDI’s General Counsel Division at (512) 676-6551 or visit the Corrections Procedure section of
TDI’s website at www.tdi.texas.gov.
Texas Department of Insurance | www.tdi.texas.gov
1/1