Form MO375-0049 "Certificate of Registration Application for Utilization Review Agents" - Missouri

What Is Form MO375-0049?

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

Form Details:

  • Released on November 1, 2019;
  • The latest edition provided by the Missouri Department of Commerce and 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 fillable version of Form MO375-0049 by clicking the link below or browse more documents and templates provided by the Missouri Department of Commerce and Insurance.

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Download Form MO375-0049 "Certificate of Registration Application for Utilization Review Agents" - Missouri

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MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
CERTIFICATE OF REGISTRATION APPLICATION
NEW APPLICATION
FOR UTILIZATION REVIEW AGENTS
RENEWAL APPLICATION
FOR THE REGISTRATION PERIOD
NAIC COCODE/GROUP (if applicable)
THIS APPLICATION FOR CERTIFICATION AS AN UTILIZATION REVIEW AGENT IS MADE BY:
1. NAME
FEIN
2. THE APPLICANT IS THE FOLLOWING TYPE OF BUSINESS ENTITY; CHECK ONLY ONE (1) ENTITY:
INDIVIDUAL
PARTNERSHIP
CORPORATION
LLC
OTHER
3. BUSINESS STREET ADDRESS (STREET, CITY, STATE, ZIP CODE) (DO NOT USE A POST OFFICE BOX)
4. BUSINESS MAILING ADDRESS (STREET OR POST OFFICE BOX, CITY, STATE, ZIP CODE)
EMAIL OF CONTACT
5. BUSINESS TELEPHONE NUMBER
COMPANY WEBSITE
6. IF APPLICANT IS A CORPORATION, THEN PROVIDE THE STATE OF INCORPORATION
7. PLEASE LIST ANY OTHER LICENSES ISSUED BY THE MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
8. LIST ALL OTHER LOCATIONS, PROVIDING COMPLETE ADDRESSES AND TELEPHONE NUMBERS (ATTACH A SEPARATE SHEET TO THE APPLICATION IF NECESSARY)
ADDRESS (P.O. BOX, STREET, CITY, STATE, ZIP CODE)
TELEPHONE NUMBER
9. PROVIDE THE NAMES AND BUSINESS ADDRESSES OF ALL OFFICERS, DIRECTORS, AND PARTNERS
NAME
BUSINESS ADDRESS
10. NAME, ADDRESS, AND PROFESSIONAL MEDICAL LICENSE NUMBER OF YOUR MISSOURI LICENSED MEDICAL DIRECTOR
(376-1351 RSMO.)
NAME
BUSINESS ADDRESS
MISSOURI LICENSE #
MO 375-0049 (11-19)
L/H
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MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
CERTIFICATE OF REGISTRATION APPLICATION
NEW APPLICATION
FOR UTILIZATION REVIEW AGENTS
RENEWAL APPLICATION
FOR THE REGISTRATION PERIOD
NAIC COCODE/GROUP (if applicable)
THIS APPLICATION FOR CERTIFICATION AS AN UTILIZATION REVIEW AGENT IS MADE BY:
1. NAME
FEIN
2. THE APPLICANT IS THE FOLLOWING TYPE OF BUSINESS ENTITY; CHECK ONLY ONE (1) ENTITY:
INDIVIDUAL
PARTNERSHIP
CORPORATION
LLC
OTHER
3. BUSINESS STREET ADDRESS (STREET, CITY, STATE, ZIP CODE) (DO NOT USE A POST OFFICE BOX)
4. BUSINESS MAILING ADDRESS (STREET OR POST OFFICE BOX, CITY, STATE, ZIP CODE)
EMAIL OF CONTACT
5. BUSINESS TELEPHONE NUMBER
COMPANY WEBSITE
6. IF APPLICANT IS A CORPORATION, THEN PROVIDE THE STATE OF INCORPORATION
7. PLEASE LIST ANY OTHER LICENSES ISSUED BY THE MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
8. LIST ALL OTHER LOCATIONS, PROVIDING COMPLETE ADDRESSES AND TELEPHONE NUMBERS (ATTACH A SEPARATE SHEET TO THE APPLICATION IF NECESSARY)
ADDRESS (P.O. BOX, STREET, CITY, STATE, ZIP CODE)
TELEPHONE NUMBER
9. PROVIDE THE NAMES AND BUSINESS ADDRESSES OF ALL OFFICERS, DIRECTORS, AND PARTNERS
NAME
BUSINESS ADDRESS
10. NAME, ADDRESS, AND PROFESSIONAL MEDICAL LICENSE NUMBER OF YOUR MISSOURI LICENSED MEDICAL DIRECTOR
(376-1351 RSMO.)
NAME
BUSINESS ADDRESS
MISSOURI LICENSE #
MO 375-0049 (11-19)
L/H
11. Has the applicant, or any one (1) if its incorporators, owners, partners, officers, directors or employees performing utilization reviews
had any of the following, in this state or any other state, since the last application for renewal was filed:
Yes
No
an application for a utilization review agent license or similar license denied, revoked, or suspended
paid a fine or forfeiture in connection with such license
had any professional, vocational or business license denied, suspended or revoked by any public authority
If the answer to any item is yes, then attach a complete explanation.
12. Attach a cashier’s check or money order made payable to the Missouri Department of Commerce and Insurance in the total amount
of $1,000. Hereafter the annual registration fee of $500 is due not later than the anniversary date of the original certification.
13. The applicant, being first duly sworn, states that s/he has completed this application or that s/he has read the application and
knows its contents and its attachments; that to the best of his/her knowledge and belief the statement made upon this application
and upon all attachments are true, correct, and complete in every material respect. Do not contain any statement which, under
the circumstances under which it was made, would be false or misleading in respect to any material fact. That s/he has read and
understands the laws of the state of Missouri pertaining to utilization review and utilization review agents. The applicant further
certifies, under oath, that it complies with all laws regulating Utilization Review Agents, including Sections 374.510 and 376.1350 -
376.1390, RSMo.
INDIVIDUAL SIGNATURE
IF THE APPLICANT IS AN
TYPE INDIVIDUAL NAME
INDIVIDUAL
PARTNER SIGNATURE
IF THE APPLICANT IS A
TYPE MANAGING GENERAL PARTNER NAME
PARTNERSHIP
OFFICER SIGNATURE
IF THE APPLICANT IS A
CORPORATION/LLC
TYPE OFFICER NAME AND TITLE
NOTARY PUBLIC
NOTARY PUBLIC EMBOSSER SEAL
STATE OF
COUNTY
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW.
DAY OF
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
14. MAIL THIS COMPLETED APPLICATION AND FEE TO:
MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
P.O. BOX 4001
JEFFERSON CITY MO 65102-4001
MO 375-0049 (11-19)
STATE OF MISSOURI
DEPARTMENT OF COMMERCE AND INSURANCE
CLIENT INFORMATION FOR UTILIZATION REVIEW AGENTS
CLIENT NAME
COMPLETE ADDRESS
PHONE NUMBER
CONTACT NAME
CONTACT EMAIL ADDRESS
1.
2.
3.
4.
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MO 375-0049 (11-19)
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