Clean State License

CMS-10118.CLEAN-State license.doc

Medicare Advantage Applications - Part C

Clean State 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

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