Get Doc 311 Utilization Review - Comppharma

This guide provides a clear and supportive approach to filling out the DOC 311 Utilization Review - CompPharma form online. By following these steps, users can efficiently complete the necessary application for utilization review registration.

Follow the steps to complete the application form successfully.

1. Click the 'Get Form' button to obtain the DOC 311 Utilization Review form and open it in the editing tool.
2. In the form, start by entering your FEIN number in the designated field at the top of the document.
3. Provide the name of the applicant in the specified section clearly and accurately.
4. Fill in the principal business address, ensuring that it reflects your current office location.
5. Enter the telephone and fax numbers, along with the normal business hours for the applicant.
6. List the name, telephone number, and email address of the contact person for inquiries related to the application.
7. If there are any branch offices, provide their addresses, phone numbers, and fax numbers in the respective fields.
8. Indicate whether the applicant intends to transact business under a fictitious name by selecting 'Yes' or 'No.' If 'Yes,' specify the fictitious name.
9. Select the appropriate type of business organization from the provided options.
10. For partnerships or associations, list the full names and addresses of all members. For corporations, provide the names and addresses of all officers.
11. Input the name of the Medical Director and the state where they are licensed to practice as required.
12. Confirm that only the persons named in the certificate will be authorized to act under it by selecting the appropriate response.
13. Complete the declaration statement with the signature(s) of the applicant or authorized representatives.
14. Attach the required registration fee of $250.00, if applicable, along with a summary of the utilization review plan and appeal procedures.
15. Finally, save any changes, download, print, or share the completed form as necessary for submission.

Begin completing your DOC 311 Utilization Review - CompPharma form online today.