[DC GOVERNMENT] DOH Reporting Form (Bill of Rights Program)

Section 1 of 1 in this document

DOH Reporting Form (Bill of Rights Program)

DISTRICT OF COLUMBIA GOVERNMENT
DEPARTMENT OF HEALTH

(Health Benefits Plan Members Bill of Rights Program)
Reporting Form
(DC CODE 44−301.10, 2001 Edition)

Reporting Period:

NAIC#:

Months Reported:

Company Name:

Staff Contact:

Staff Title

Phone Number

Staff Fax

Staff Email Address

IMPORTANT

If your company has no grievances to report for this filing period, and/or
is exempt from filing a report with the District of Columbia, Department
of Health, please respond as appropriate, attach appropriate doucments,
date and sign below and return only this first page of the form and the
documents to the address below:

Mark One which applies

Our Company has NO GRIEVANCES to report for this filing period

Our Company is exempt from filing a Report of Grievances. Documentation granting this exemption is attached.

Authorized Signature (Initials Please)

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Date

Title

Phone Number

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DOH Reporting Form (Bill of Rights Program)

Mailing Address

Mailing Address:

Mark One which applies

Authorized Signature (Initials Please)

Date