PFFS License

PFFS License.doc

Medicare Advantage Applications

PFFS License

OMB: 0938-0935

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license.doc - State License






State



Applicant

Licensed?

Yes or No





Type of License


Does State Regulate Medicare?

Yes or No




Which Medicare Activities are Regulated by the State?i


Restricted Reserve Requirements

If yes, give amount



State Regulator=s

Name, Address

Phone #






































































































































































































i. Include activities such as Medicare marketing, financial performance, benefits, grievances, etc.


pffslice.doc 6/2002

File Typeapplication/msword
File Titlehcpplice
AuthorSylvia Hendel
Last Modified ByCMS
File Modified2006-03-24
File Created2006-03-24

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