Form HIPMC-MD-1 "Medical Director Report Form" - Kentucky

What Is Form HIPMC-MD-1?

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

Form Details:

  • Released on March 1, 2021;
  • The latest edition provided by the Kentucky 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 HIPMC-MD-1 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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KENTUCKY DEPARTMENT OF INSURANCE
DIVISIONS OF HEALTH AND LIFE INSURANCE AND MANAGED CARE
MEDICAL DIRECTOR REPORT FORM
In accordance with 806 KAR 17:230 and 806 KAR 17:280, section 4, an insurer/private review agent shall
submit the information specified on this form, as well as a biographical resume of the Medical Director
and Alternative Medical Director to the KY Department of Insurance, via email to
DOI.UtilizationReview@ky.gov. This format shall be used to report information initially and to report any
subsequent change in the information within thirty (30) days of the change.
MEDICAL DIRECTOR
Name
_____________________________________________________
State(s) of Medical Licensure
_____________________________________________________
KY Medical Licensure Number _____________________________________________________
Residence Address
_____________________________________________________
_____________________________________________________
Business Address
_____________________________________________________
_____________________________________________________
Business Telephone Number
_____________________________________________________
Alternative Medical Director
Name
_____________________________________________________
State(s) of Medical Licensure
_____________________________________________________
KY Medical Licensure Number _____________________________________________________
Residence Address
_____________________________________________________
_____________________________________________________
Business Address
_____________________________________________________
_____________________________________________________
Business Telephone Number
_____________________________________________________
HIPMC-MD-1 03/2021
KENTUCKY DEPARTMENT OF INSURANCE
DIVISIONS OF HEALTH AND LIFE INSURANCE AND MANAGED CARE
MEDICAL DIRECTOR REPORT FORM
In accordance with 806 KAR 17:230 and 806 KAR 17:280, section 4, an insurer/private review agent shall
submit the information specified on this form, as well as a biographical resume of the Medical Director
and Alternative Medical Director to the KY Department of Insurance, via email to
DOI.UtilizationReview@ky.gov. This format shall be used to report information initially and to report any
subsequent change in the information within thirty (30) days of the change.
MEDICAL DIRECTOR
Name
_____________________________________________________
State(s) of Medical Licensure
_____________________________________________________
KY Medical Licensure Number _____________________________________________________
Residence Address
_____________________________________________________
_____________________________________________________
Business Address
_____________________________________________________
_____________________________________________________
Business Telephone Number
_____________________________________________________
Alternative Medical Director
Name
_____________________________________________________
State(s) of Medical Licensure
_____________________________________________________
KY Medical Licensure Number _____________________________________________________
Residence Address
_____________________________________________________
_____________________________________________________
Business Address
_____________________________________________________
_____________________________________________________
Business Telephone Number
_____________________________________________________
HIPMC-MD-1 03/2021