CMS-10433 Reinsurance Program and Risk Adjustment Program

OMB control number: 0938-1187
Expiration Date: XX/XX/20XX

Risk Adjustment Program and Payment Operations Data Requirements
CMS will collect data required from issuers for the permanent Risk Adjustment program established
by the Affordable Care Act of 2010. In addition, CMS will collect banking information to remit
payments to applicable entities.
To ensure accurate information, consistent presentation, and minimize the burden on applicants,
extensive analysis has been conducted to determine the minimum data necessary for administering
the Risk Adjustment program and payment operations.
Administrative Data Elements (as applicable)
The section requests that issuers, self-insured and third party administrators when providing
services on behalf of either provide basic information required to identify them to facilitate
communications and necessary program operations. Data will be pre-populated from HIOS or other
templates whenever possible.
Issuer, Self-Insured and TPA Data
1. HIOS Issuer ID
2. HIOS Company ID
3. State
4. Exchange Market Coverage
5. Company Legal Name
6. TIN
7. Not-for-Profit
8. NAIC Company Code
9. NAIC Group Code
10. Name of Holding Company
11. Legal Name
12. Marketing Name
13. Company Address: Address
14. Company Address: Address 2
15. Company Address: City
16. Company Address: State
17. Company Address: Zip Code
18. Issuer: Address
19. Issuer: Address 2
20. Issuer: City
21. Issuer: State
22. Issuer: Zip
Contacts
23. Main Company Contact: First Name
24. Main Company Contact: Last Name
PRA DISCLOSURE:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-1187, expiration date is XX/XX/20XX.
The time required to complete this information collection is estimated to take up to 24.50 hours per issuer per year, including the time to
review instructions, gather the information needed, and complete and review the information collection. If you have comments concerning
the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send
applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office.
Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control
number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your
documents, please contact Nicole Levesque at [email protected].

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Main Contact: E-mail
Main Company Contact: Phone Number
Main Company Contact: Phone Ext
CEO: First Name
CEO: Last Name
CEO: E-mail
CEO: Phone Number
CEO: Phone Ext
CFO: First Name
CFO: Last Name
CFO: E-mail
CFO: Phone Number
CFO: Phone Number Ext
Compliance Officer: First Name
Compliance Officer: Last Name
Compliance Officer: E-mail
Compliance Officer: Phone Number
Compliance Officer: Phone Number Ext
Compliance Officer: E-mail
Enrollment Contact: First Name
Enrollment Contact: Last Name
Enrollment Contact: Phone Number
Enrollment Contact: Phone Number Ext
Enrollment Contact: E-mail
System Contact: First Name
System Contact: Last Name
System Contact: Phone Number
System Contact: Phone Number Ext
System Contact: E-mail
Payment Contact: First Name
Payment Contact: Last Name
Payment Contact: Phone Number
Payment Contact: Phone Number Ext
Payment Contact: E-mail
HIPAA Security Officer: First Name
HIPAA Security Officer: Last Name
HIPAA Security Officer: Phone Number
HIPAA Security Officer: Phone Number Ext
HIPAA Security Officer: E-mail
Complaints Tracking Contact: First Name
Primary Contact: Individual or Small Group
Individual Market Contact: First Name
Individual Market Contact: Last Name
Individual Market Contact: Phone Number
Individual Market Contact: Phone Number Ext
Individual Market Contact: E-mail
SHOP Contact: First Name
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SHOP Contact: Last Name
SHOP Contact: Phone Number
SHOP Contact: Phone Number Ext
SHOP Contact: E-mail
APTC/CSR Contact: First Name
APTC/CSR Contact: Last Name
APTC/CSR Contact: Phone Number
APTC/CSR Contact: Phone Number Ext
APTC/CSR Contact: Email
Risk Adjustment Contact: First Name
Risk Adjustment Contact: Last Name
Risk Adjustment Contact: Phone Number
Risk Adjustment Contact: Phone Number Ext
Risk Adjustment Contact: Email
Financial Transfers Contact: First Name
Financial Transfers Contact: Last Name
Financial Transfers Contact: Phone Number
Financial Transfers Contact: Phone Number Ext
Financial Transfers Contact: E-mail
Third Party Administrator (TPA) ID
Third Party Administrator (TPA) Name
Third Party Administrator (TPA) Process
Third Party Administrator (TPA) Process URL/EDI Gateway Info
Third Party Administrator (TPA) Confirmation of Services

Miscellaneous
96. Do you have a TPA that currently provides services for the following processes:
Marketplace Enrollment (Y/N), Claims Processing (Y/N), Edge Server (Y/N)
97. Will you allow employees to “buy up” to a higher metal-level coverage than their
employer is offering?
State Licensure and Good Standing Documentation
State licensure documentation necessary to demonstrate that an issuer is licensed and has authority
to sell all applicable products in the services areas in which it intends to offer those products. If
license and certificate of authority are not in possession for all service areas, attestation that license
and certificate of authority will be obtained and a projected date of obtaining license.
Good standing documentation necessary to demonstrate that an issuer is in compliance with all
applicable State solvency requirements and other relevant State regulatory requirements.
Attestations (as applicable)
1. The following applies to applicants participating in the risk adjustment program inside
and/or outside of the Exchange (Marketplace). Applicant attests that it will:
a) adhere to the risk adjustment standards and requirements set by HHS in theannual
HHS notice of benefit and payment parameters (45 CFR Subparts G and H);
b) remit charges to HHS under the circumstances described in 45 CFR 153.610;
c) establish dedicated and secure server environments to host enrollee claims, encounter,
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and enrollment information for the purpose of performing risk adjustment operations
for all plans offered;
d) allow proper interface between the dedicated server environment and special,
dedicated CMS resources that execute the risk adjustment operations;
e) ensure the transfer of timely, routine, and uniform data from local systems to the
dedicated server environment using CMS-defined standards, including file formats
and processing schedules;
f) comply with all information collection and reporting requirements approved through
the Paperwork Reduction Act of 1995 and having a valid OMB control number for
approved collections. The Issuer will submit all required information in a CMSestablished manner and common data format;
g) cooperate with CMS, or its designee, through a process for establishing the server
environment to implement these functions, including systems testing and operational
readiness;
h) use sufficient security procedures to ensure that all data available electronically are
authorized and protect all data from improper access, and ensure that the operations
environment is restricted to only authorized users;
i) provide access to all original source documents and medical records related to the
eligible organization’s submissions, including the beneficiary's authorization and
signature to CMS or CMS’ designee, if requested, for audit;
j) retain all original source documentation and medical records pertaining to any such
particular claims data for a period of at least 10 years;
k) be responsible for all data submitted to CMS by itself, its employees, or its agents and
based on best knowledge, information, and belief, submit data that are accurate,
complete, and truthful;
l) all information, in any form whatsoever, exchanged for risk adjustment shall be
employed solely for the purposes of operating the premium stabilization programs
and financial programs associated with state markets, including but not limited to, the
calculation of user fees to fund such programs, oversight, and any validation and
analysis that CMS determines necessary;
Under the False Claims Act, 31 U.S.C. §§ 3729-3733, those who knowingly submit, or
cause another person or entity to submit, false claims for payment of government funds
are liable for three times the government’s damages plus civil penalties of $5,500 to
$11,000 per false claim. 18 U.S.C. 1001 authorizes criminal penalties against an
individual who in any matter within the jurisdiction of any department or agency of the
United States knowingly and willfully falsifies, conceals, or covers up by any trick,
scheme, or device, a material fact, or makes any false, fictitious or fraudulent statements
or representations, or makes any false writing or document knowing the same to contain
any false, fictitious or fraudulent statement or entry. Individual offenders are subject to
fines of up to $250,000 and imprisonment for up to 5 years. Offenders that are
organizations are subject to fines up to $500,000. 18 U.S.C. 3571(d) also authorizes fines
of up to twice the gross gain derived by the offender if it is greater than the amount
specifically authorized by the sentencing statute. Applicant acknowledges the False
Claims Act, 31 U.S.C. §§ 3729-3733.
Applicant attests to provide and promptly update when applicable changes occur in its
Tax Identification Number (TIN) and associated legal entity name as registered with the
Internal Revenue Service, financial institution account information, and any other
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information needed by CMS in order for the applicant to receive invoices, demandletters,
and payments under the risk adjustment program, as well as, any reconciliations of the
aforementioned programs.
Applicant attests that it will develop, operate and maintain viable systems, processes,
procedures and communication protocols to accept payment-related information
submitted by CMS.

Plan Data Elements (as applicable)
The following is a list of the specific plan-level identification information to be provided for
non-Exchange plans in the individual and small group market.
1. Plan ID
2. Plan Marketing Name
3. HIOS Product ID
4. Market Type
5. Exchange QHP? (Y/N)
 If off-Exchange, is it the same or substantially the same as a certified Exchange QHP?
Same, Substantially the same, No
 If the same or substantially the same as a certified Exchange QHP, provide HIOS Plan
ID (14-digit standard component) for the certified Exchange QHP.
6. Level of Coverage
7. Issuer calculated actuarial value?
8. Metal Level
9. Child–Only Offering
10. Child–Only Plan ID
11. Plan Type
12. New or Existing Plan Indicator
13. Plan Effective Date
14. Plan Expiration Date
15. Maximum Out–of–Pocket Individual In–Network for EHBs (combined amount for
medical and drug)
16. Maximum Out–of–Pocket Family In–Network for EHBs (combined amount for medical
and drug)
17. Federal Tax ID
18. Non-grandfathered (Y/N)
19. Type of Plan Offering: Student Health Plan (Y/N), Medicaid (Y/N), Basic Health Plan
(Y/N), Excepted Benefit Plan-Not Standalone Dental (Y/N), Short Term Limited
Duration Plan (Y/N), Other (Y/N)
Rating Tables and Issuer Business Rules (as applicable)
The following is a list of the specific rating table and issuer business rules data elements to be
collected for non-Exchange plans in the individual and small group market.
1. Product ID
2. Plan ID (Standard Component)
3. Rate Effective Date
4. Rate Expiration Date
5. Rating Method
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8.
9.

Is there a maximum age for a dependent?
How is age determined for rating and eligibility purposes?
How is tobacco status determined for subscribers and dependents?
What relationships between primary and dependent are allowed, and is the dependent
required to live in the same household as the primary subscriber?
10. Rating Area ID
11. Tobacco
12. Age
13. Individual Rate
14. Issuer ID
15. Product Level Rules
16. Plan Level Rules (14-digit number that identifies the plan)
17. Are you in a community rated state? (Y/N) If yes, are your premiums based on family
tiering? (Y/N)
18. In which order are children rated, oldest to youngest or youngest to oldest?
19. What is the maximum number of underage dependents for this policy?
20. Medical, Dental, or Both Indicator
21. Medical or Dental Rule
Banking Data (as applicable)
The following is a list of the specific banking data to be collected from all entities eligible to
receive payments.
1. Reason for Submission: New EFT Authorization (Y/N), Revision to Current
Authorization (e.g. account or financial institution changes ) (Y/N)
2. Check here if EFT payment is being made to the Affiliate of the Entity (Attach
letter authorizing EFT payments to the Affiliated Entity)
3. Since your last EFT authorization agreement submission, have you had a Change of
Ownership and/or Change of Address? (Y/N) If yes, submit a change of information
prior to accompanying this EFT authorization.
4. Entity ID
5. Vendor ID
6. HIOS ID
7. Entity name (Legal) – Legal entity name should be the same name provided to the
Internal Revenue Service on Form W-9, Request for Taxpayer Identification Number
(TIN) and Certification
8. Entity: Name (DBA)
9. Entity: Name (Division)
10. Entity: Address
11. Entity: Address 2 – Address should include routing information (e.g. Attention:
Accounting Department)
12. Entity: City
13. Entity: State

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Entity: Zip Code
Entity: Country
Entity: TIN
List of all Entity Affiliated HIOS IDs
List of all Entity Affiliated HIOS ID Names
List of all Entity Affiliated HPID IDs
IRS 1099: Address
IRS 1099: Address 2
IRS 1099: City
IRS 1099: State
IRS 1099: Zip Code
IRS 1099: Country
Copy of Voided Check
Letter from Financial Institution for Account Validation
Financial Institution Routing Transit Number
Entity Depositor Account Number
Type of Account: Checking or Savings
Payment Amount
Invoice Number
Invoice Date
Check Payment Remittance Contact: Title (up to four instances)
Check Payment Remittance Contact: First Name (up to four instances)
Check Payment Remittance Contact: Last Name (up to four instances)
Check Payment Remittance Contact: Phone Number (up to four instances)
Check Payment Remittance Contact: Phone Number Ext (up to four instances)
Check Payment Remittance Contact: E-mail (up to four instances)
Check Payment Remittance Contact: Address (up to four instances)
Check Payment Remittance Contact: Address 2 (up to four instances)
Check Payment Remittance Contact: City (up to four instances)
Check Payment Remittance Contact: State (up to four instances)
Check Payment Remittance Contact: Zip Code (up to four instances)
Check Payment Remittance Contact: Country (up to four instances)
EFT Banking Information: Title (up to four instances)
EFT Banking Information: First Name (up to four instances)
EFT Banking Information: Last Name (up to four instances)
EFT Banking Information: Phone Number (up to four instances)
EFT Banking Information: Phone Number Ext (up to four instances)
EFT Banking Information: E-mail (up to four instances)
EFT Banking Information: Bank Name (up to four instances)
EFT Banking Information: Address (up to four instances)
EFT Banking Information: Address 2 (up to four instances)
EFT Banking Information: City (up to four instances)
EFT Banking Information: State (up to four instances)
EFT Banking Information: Zip Code (up to four instances)
EFT Banking Information: Country (up to four instances)
Profit/Non-Profit Indicator
Change of Ownership Date
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61. Business Line to which this banking information is applicable – Also referred to as
“Business Line” or “Program Type;” includes FFM User Fees, Advanced Premium Tax
Credits (APTC), Cost Sharing Reductions (CSR), , and Risk Adjustment programs.
62. Financial Reporting IP Address
63. Authorized/Delegated Official: Title
64. Authorized/Delegated Official: First Name
65. Authorized/Delegated Official: Last Name
66. Authorized/Delegated Official: Phone Number
67. Authorized/Delegated Official: Phone Number Ext
68. Authorized/Delegated Official: E-mail
69. Authorized/Delegated Official: Signature
70. Date of Authorization
71. Payment Contact: First Name
72. Payment Contact: Last Name
73. Payment Contact: Phone Number
74. Payment Contact: Phone Number Ext
75. Payment Contact: E-mail
76. Financial Transfers Contact: First Name
77. Financial Transfers Contact: Last Name
78. Financial Transfers Contact: Phone Number
79. Financial Transfers Contact: Phone Number Ext
80. Financial Transfers Contact: E-mail
81. Electronic Funds Transfer Authorization Agreement: I hereby authorize the Centers for
Medicare & Medicaid Services (CMS) to initiate credit entries, and in accordance with
31 CFR part 210.6(f) initiate adjustments for any duplicate or erroneous entries made in
error to the account indicated above. I hereby authorize the financial institution/bank
named above to credit and/or debit the same to such account. CMS may assign its rights
and obligations under this agreement to CMS’ designated contractor. CMS may change
its designated contractor at CMS’ discretion. If payment is being made to an account
controlled by an Affiliated Entity, referred to as Payee Group, the Entity, also known as
Health Insurance Company, hereby acknowledges that payment to the Payee Group
under these circumstances is still considered payment to the Health Insurance
Company, and the Health Insurance Company authorizes the forwarding of payments to
the Payee Group. If the account is drawn in the Health Insurance Company’s name, or
the Legal Business Name of the Health Insurance Company, the said Health Insurance
Company certifies that he/she has sole control of the account referenced above, and
certifies that all arrangements between the Financial Institution and the said Health
Insurance Company are in accordance with all applicable CMS regulations and
instructions. This authorization agreement is effective as of the signature date below
and is to remain in full force and effect until CMS has received written notification
from me of its termination in such time and such manner as to afford CMS and the
Financial Institution a reasonable opportunity to act on it. CMS will continue to send
the direct deposit to the Financial Institution indicated above until notified by me that I
wish to change the Financial Institution receiving the direct deposit. If my Financial
Institution information changes, I agree to submit to CMS an updated signed EFT
Authorization Agreement.
82. Are you an insurance company?
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Effective Date for Financial Information
Financial Authority Contact: Title
Financial Authority Contact: First Name
Financial Authority Contact: Last Name
Financial Authority Contact: Phone Number
Financial Authority Contact: E-mail
Financial Institution: Name
Financial Institution: City
Financial Institution: State
Financial Institution: Zip
Financial Institution Contact: First Name
Financial Institution Contact: Last Name
Financial Institution Contact: Phone Number
Financial Institution Contact: Phone Number Ext
Financial Information Form Contact: First Name
Financial Information Form Contact: Last Name
Financial Information Form Contact: Title
Financial Information Form Contact: Phone Number
Financial Information Form Contact: Phone Number Ext
Financial Information Form Contact: Email
Payee Group: TIN
Payee Group Contact: Title
Payee Group Contact: First Name
Payee Group Contact: Last Name
Payee Group Contact: Phone Number
Payee Group Contact: Phone Number Ext
Payee Group Contact: Email
Payee Group Contact: Address
Payee Group Billing Address: Address
Payee Group Billing Address: Attention
Payee Group Billing Address: City
Payee Group Billing Address: State
Payee Group Billing Address: Zip Code
Is the payee group an Organization Level Payee?
Legal Business Name with no special characters except ampersands and hyphens
Type of Corporate Entity
Copy of W-9

EDGE Server Registration and Provisioning Data
The following is a list of the specific data required for the Edge Server registration and
provisioning process.
AWS EDGE Server Registration Data Elements
SECTION 1: ISSUER CONTACTS (primary and secondary are required)
1.
2.
3.

Primary Contact: Prefix (optional)
Primary Contact: First Name
Primary Contact: Last Name

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5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Primary Contact: Job Title (optional)
Primary Contact: email address
Primary Contact: Phone Number
Primary Contact: Phone Number Ext
Secondary Contact: Prefix (optional)
Secondary Contact: First Name
Secondary Contact: Last Name
Secondary Contact: Job Title (optional)
Secondary Contact: email address
Secondary Contact: Phone Number
Secondary Contact: Phone Number Ext

SECTION 2: ISSUER SUPPLEMENTAL CONTACTS (maximum of 2; optional)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext
Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext

SECTION 3: ISSUER AWS EDGE SERVER INFORMATION - SELF HOSTED
1.
2.
3.
4.
5.
6.
7.

Name of EDGE Server (provided by the Issuer)
Insurance Company - Legal name of the insurance company responsible for the EDGE Server
Issuer Name - Legal name of the issuer responsible for the EDGE Server
HIOS Issuer ID
EDGE Server Size - small, medium, or large
Amazon Web Services (AWS) Region - US East, US West - Oregon, US West – N.California
AWS Account Information – includes AWS account number for the registering organization and
AWS Key Pair Name (AWS key name associated with the AWS account that is used to provision
the EDGE server)

SECTION 4: THIRD PARTY ADMINISTRATOR AWS EDGE SERVER INFORMATION
- TPA HOSTED
1.
2.
4.
5.
6.
7.

Name of EDGE Server
TPA Company - Legal name of the TPA company hosting the EDGE Server 3. Issuer Name Legal name of the issuer responsible for the EDGE Server
TPA Identifier – (issuer selects from a list)
EDGE Server Size - small, medium, or large
Amazon Web Services (AWS) Region - US East, US West - Oregon, US West – N.California
AWS Account Information – includes AWS account number for the registering organization and
AWS Key Pair Name (AWS key name associated with the AWS account that is used to provision
the EDGE server)

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SECTION 5: TPA CONTACTS (primary and secondary required) - TPA HOSTED
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Primary Contact: Prefix (optional)
Primary Contact: First Name
Primary Contact: Last Name
Primary Contact: Job Title (optional)
Primary Contact: email address
Primary Contact: Phone Number
Primary Contact: Phone Number Ext
Secondary Contact: Prefix (optional)
Secondary Contact: First Name
Secondary Contact: Last Name
Secondary Contact: Job Title (optional)
Secondary Contact: email address
Secondary Contact: Phone Number
Secondary Contact: Phone Number Ext

SECTION 6: TPA SUPPLEMENTAL CONTACTS (maximum of 2; optional) - TPA
HOSTED
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext
Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext

Issuer On-Premise EDGE Server Registration Data Elements
SECTION 1: ISSUER CONTACTS (primary and secondary are required)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Primary Contact: Prefix (optional)
Primary Contact: First Name
Primary Contact: Last Name
Primary Contact: Job Title (optional)
Primary Contact: email address
Primary Contact: Phone Number
Primary Contact: Phone Number Ext
Secondary Contact: Prefix (optional)
Secondary Contact: First Name
Secondary Contact: Last Name
Secondary Contact: Job Title (optional)
Secondary Contact: email address
Secondary Contact: Phone Number

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14. Secondary Contact: Phone Number Ext

SECTION 2: ISSUER SUPPLEMENTAL CONTACTS (maximum of 2; optional)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext
Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext

SECTION 3: ISSUER EDGE SERVER INFORMATION - ON PREMISE SELF HOSTED
1.
2.

Name of EDGE Server (provided by the Issuer)
Insurance Company - Legal name of the insurance company responsible for the EDGE Server 3.
Issuer Name - Legal name of the issuer responsible for the EDGE Server 4. HIOS Issuer ID 5.
EDGE Server Size - small, medium, or large

SECTION 4: THIRD PARTY ADMINISTRATOR EDGE SERVER INFORMATION ONPREMISE - TPA HOSTED
1.
2.
4.
5.

Name of EDGE Server
TPA Company - Legal name of the TPA company hosting the EDGE Server 3. Issuer Name Legal name of the issuer responsible for the EDGE Server
TPA Identifier - (issuer selects TPA from list)
EDGE Server Size - small, medium, or large

SECTION 5: TPA CONTACTS (primary and secondary required) - TPA HOSTED
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Primary Contact: Prefix (optional)
Primary Contact: First Name
Primary Contact: Last Name
Primary Contact: Job Title (optional)
Primary Contact: email address
Primary Contact: Phone Number
Primary Contact: Phone Number Ext
Secondary Contact: Prefix (optional)
Secondary Contact: First Name
Secondary Contact: Last Name
Secondary Contact: Job Title (optional)
Secondary Contact: email address
Secondary Contact: Phone Number
Secondary Contact: Phone Number Ext

SECTION 6: TPA SUPPLEMENTAL CONTACTS (maximum of 2; optional) - TPA
HOSTED
1.

Supplemental Contact: Prefix (optional)

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2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext
Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number

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