Get Ct Public Health Fee Assessment Request 2019-2025

This guide provides comprehensive instructions for completing the CT Public Health Fee Assessment Request form online. It is designed to assist users in accurately filling out each section of the form to ensure compliance with reporting requirements.

Follow the steps to complete the online form efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Select your filing category by choosing between 'Domestic Insurer' or 'Health Center'. Ensure to mark the appropriate option.
3. In the 'Reporting Entity' section, enter the company name in the designated field. This should be the legal name of the entity submitting the form.
4. Fill in the 'Street Address', 'City, State, Zip' fields with the complete address of the reporting entity.
5. Provide the name of a contact person in the 'Contact Person' field. This should be the individual who can answer any questions regarding the report.
6. Enter the phone number and email of the contact person in the respective fields. The email provided will receive assessment invoices.
7. Report the 'Number of Insured or Enrolled Lives in CT'. If there are none, indicate this by writing 'NONE'. Ensure that the number only includes those lives that are not part of Medicare or state-administered programs.
8. In the 'Certification' section, the reporting representative must sign and date the form. Make sure that the printed name and title are also filled in correctly.
9. Verify all entries for accuracy and completeness to avoid late fees or penalties.
10. Once you have reviewed the form, save your changes. You may also download, print, or share the completed form as needed.

Complete your CT Public Health Fee Assessment Request online today!