Get Ct Health And Welfare Fee (childhood Vaccinations) Assessment Request 2019

This guide provides comprehensive instructions for filling out the CT Health And Welfare Fee (Childhood Vaccinations) Assessment Request form online. Whether you are an insurer or a third-party administrator, these steps will help ensure your submission is accurate and timely.

Follow the steps to successfully complete the assessment request form.

1. Click ‘Get Form’ button to access the CT Health And Welfare Fee (Childhood Vaccinations) Assessment Request form and open it in your preferred document editor.
2. Begin with the 'Filling As' section. Select the appropriate option that applies to your entity (e.g., Insurer, Exempt Insurer, TPA) and provide an explanation if the 'Exempt Insurer' option is checked.
3. In the 'Reporting Entity' section, enter the following information: - Entity Name - Street Address - City, State, Zip Code - Contact Person - Phone Number - Email Address (This is crucial for communications regarding the report).
4. Proceed to the 'Number of Insured or Enrolled Lives in CT' section. Report the total number of individuals insured or enrolled in Connecticut as of May 1st, 2019, for the specified coverage types. If there are none, indicate 'NONE'.
5. Complete the 'Certification' section by providing: - Signature of the authorized person - Printed name - Title - Date of signing (make sure that the person signing is aware of their responsibilities).
6. After reviewing all entered information for accuracy, you can save your changes, download the filled form, print it for your records, or share it as required.

Complete your CT Health And Welfare Fee (Childhood Vaccinations) Assessment Request form online to ensure timely submission.