Form C "Proof of Service of Papers Required for Non-network Providers of Emergency Care Services Health Care Reimbursement for Emergency Care Arbitration" - Delaware

What Is Form C?

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

Form Details:

  • The latest edition provided by the Delaware 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 fillable version of Form C by clicking the link below or browse more documents and templates provided by the Delaware Department of Insurance.

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Download Form C "Proof of Service of Papers Required for Non-network Providers of Emergency Care Services Health Care Reimbursement for Emergency Care Arbitration" - Delaware

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Regulation 1316 – Form C
Proof of Service of Papers Required for Non-Network Providers of Emergency Care
Services Health Care Reimbursement for Emergency Care Arbitration
I certify that on the ________ day of __________________, 20____, in addition to the
filing provided by the Insurance Commissioner, I sent a copy of the
______ Petition for Arbitration with required attachments
______ Response to the Petition for Arbitration with required attachments
______ Other (please describe) _______________________________________
__________________________________________________________
to the following person(s) by:
______ Certified mail, return receipt requested
______ First-class mail, postage-prepaid
Name
Address
Name
Address
Name
Address
The following is required by the person making this certification:
Name of Party
Address of Party
Signature of Party
NOTE: Save all proofs of mailing and return receipt(s) for verification by the Arbitrator.
Regulation 1316 – Form C
Proof of Service of Papers Required for Non-Network Providers of Emergency Care
Services Health Care Reimbursement for Emergency Care Arbitration
I certify that on the ________ day of __________________, 20____, in addition to the
filing provided by the Insurance Commissioner, I sent a copy of the
______ Petition for Arbitration with required attachments
______ Response to the Petition for Arbitration with required attachments
______ Other (please describe) _______________________________________
__________________________________________________________
to the following person(s) by:
______ Certified mail, return receipt requested
______ First-class mail, postage-prepaid
Name
Address
Name
Address
Name
Address
The following is required by the person making this certification:
Name of Party
Address of Party
Signature of Party
NOTE: Save all proofs of mailing and return receipt(s) for verification by the Arbitrator.