(2) Pay the application fee established by this Subpart.
B. The application shall be on a form and accompanied by any supporting documentation required by the commissioner and shall be signed and verified by the applicant. The information required by the application shall include but need not be limited to the following:
(1) The name of the entity operating the dental referral plan and any trade or business names used by that entity in connection with the operation of the dental referral plan.
(2) The names and addresses of every officer and director of the entity operating the dental referral plan as well as the name and address of the corporate officer designated by the plan as the corporate representative to receive, review, and resolve all grievances addressed to the plan.
(3) The name and address of every person owning, directly or indirectly, five percent or more of the entity operating the dental referral plan.
(4) The principal place of business of the dental referral plan.
(5) A general description of the operation of the dental referral plan which includes a statement that the plan does not provide indemnity insurance coverage for dental services.
(6) A sample copy of a contract with an enrollee which includes a general description of enrollee's rights under the dental referral plan.
(7) A sample copy of a contract, absent fee schedule, with a provider which includes a general description of dental care provider's rights under the dental referral plan.
Acts 1995, No. 1050, §1; Redesignated from R.S. 22:2031 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
(2) Pay the application fee established by this Subpart.
B. The application shall be on a form and accompanied by any supporting documentation required by the commissioner and shall be signed and verified by the applicant. The information required by the application shall include but need not be limited to the following:
(1) The name of the entity operating the dental referral plan and any trade or business names used by that entity in connection with the operation of the dental referral plan.
(2) The names and addresses of every officer and director of the entity operating the dental referral plan as well as the name and address of the corporate officer designated by the plan as the corporate representative to receive, review, and resolve all grievances addressed to the plan.
(3) The name and address of every person owning, directly or indirectly, five percent or more of the entity operating the dental referral plan.
(4) The principal place of business of the dental referral plan.
(5) A general description of the operation of the dental referral plan which includes a statement that the plan does not provide indemnity insurance coverage for dental services.
(6) A sample copy of a contract with an enrollee which includes a general description of enrollee's rights under the dental referral plan.
(7) A sample copy of a contract, absent fee schedule, with a provider which includes a general description of dental care provider's rights under the dental referral plan.
Acts 1995, No. 1050, §1; Redesignated from R.S. 22:2031 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
(2) Pay the application fee established by this Subpart.
B. The application shall be on a form and accompanied by any supporting documentation required by the commissioner and shall be signed and verified by the applicant. The information required by the application shall include but need not be limited to the following:
(1) The name of the entity operating the dental referral plan and any trade or business names used by that entity in connection with the operation of the dental referral plan.
(2) The names and addresses of every officer and director of the entity operating the dental referral plan as well as the name and address of the corporate officer designated by the plan as the corporate representative to receive, review, and resolve all grievances addressed to the plan.
(3) The name and address of every person owning, directly or indirectly, five percent or more of the entity operating the dental referral plan.
(4) The principal place of business of the dental referral plan.
(5) A general description of the operation of the dental referral plan which includes a statement that the plan does not provide indemnity insurance coverage for dental services.
(6) A sample copy of a contract with an enrollee which includes a general description of enrollee's rights under the dental referral plan.
(7) A sample copy of a contract, absent fee schedule, with a provider which includes a general description of dental care provider's rights under the dental referral plan.
Acts 1995, No. 1050, §1; Redesignated from R.S. 22:2031 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
