Licensing of Preferred Provider Networks

BULLETIN HC-59 CERTIFICATION COMPANY NAME:_____________________________________________________________ (A SEPARATE FORM MUST BE COMPLETED FOR EACH COMPANY NAME) COMPANY ADDRESS: __________ [ ] The company is a preferred provider network as defined in Public Act No. 03-169. [ ] The company is not a preferred provider network as defined in Public Act No. 03-169. If checked, please explain why (use separate sheets if necessary): [ ] The company engages or intends to engage a preferred provider network as defined in Public Act No. 03-169. Please list PPNs with which your company contracts (use separate sheets if necessary): I, _______________________________, ______________________________of (Printed Name) (Title) ___________________________________________________, hereby certify that the (Company or Organization) information above is true and accurate. ____________________________________________ DATE SIGNED: ___________ OFFICER’S SIGNATURE Please provide the Department with the name and contact information of a person in your company that we can contact for future Bulletins or information on PPN topics: CONTACT NAME: _____________________________________________________________ CONTACT ADDRESS:____________________________________________________________ CONTACT PHONE #: ___________________ FAX #_______________________ E-MAIL ADDRESS: ___________________________________________________ Certification must be returned by December 31, 2003 to: State of Connecticut Insurance Department, Attn: Moira Herbert, P O Box 816, Hartford, CT 06142-0816