Life and Health Forms
Form Number:
APP-ASSIGN
Title:
Individual Eligibility Application for the State of Georgia Assignment System
Published:
2009
Description:
This application must be completed for individuals who are applying for coverage under the State of Georgia individual assignment system. In order to be eligible for coverage under this program, the Administrator must receive this application no later than 63 days following your termination of coverage under your group plan’s continuation of benefits. You may use the enclosed self-addressed envelope or send the application to the address above. Submission of this application does not guarantee coverage. The Administrator and/or insurance company reserves the right to review your responses to determine eligibility for coverage under this plan for you and your dependents.
Form Number:
GHBAS-1
Title:
Assignment System Managed Care Policy Form Template (GHBAS-1)
Published:
1998
Description:
Pre Certification Requirement for Assignment System Managed Care Policy.
Form Number:
GHBAS-S
Title:
Assignment System Managed Care Schedule of Benefits (GHBAS-S)
Published:
1998
Description:
Georgia Department of Insurance Managed Care Schedule of Benefits Summary.
Form Number:
GHIAS-1
Title:
Assignment System Indemnity Policy Form Template Plan A (GHIAS-1)
Published:
1998
Description:
Indemnity Pre Certification requirements.
Form Number:
GHIAS-2
Title:
Assignment System Indemnity Policy Form Template Plan B (GHIAS-2)
Published:
1998
Description:
Assignment System Indemnity Policy Form Template Plan B (GHIAS-2)
Form Number:
GHIAS-S
Title:
Assignment System Indemnity Schedule of Benefits (GHIAS-S)
Published:
1998
Description:
Assignment System Indemnity Schedule of Benefits
Form Number:
GID-057-LH-UR
Title:
Application For Certification as a Private Review Agent
Published:
2008
Description:
Application For Certification as a Private Review Agent.
Form Number:
GID-065-LH-UR
Title:
Biographical Affidavit
Published:
2008
Description:
Biographical Affidavit
Form Number:
GID-072-LH-UR
Title:
Checklist of Application Documents for initial Certification of Private Review Agents
Published:
2008
Description:
Checklist of Application Documents for initial Certification of Private Review Agents.
Form Number:
GID-072-LH-UR checklist
Title:
Checklist of Application Documents for Recertification of Private Review Agents
Published:
2008
Description:
Checklist of Application Documents for Recertification of Private Review Agents
Form Number:
GID-073-LH-UR
Title:
Annual Report Information for Utiltization Review Activities fot he Year Ended ...
Published:
2008
Description:
Annual Report Information for Utiltization Review Activities fot he Year Ended ...
Form Number:
GID-PPA1
Title:
Patient Protection Act Application for Certification
Published:
1997
Description:
Patient Protection Act Application for Certification This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.
Form Number:
H-Quest
Title:
Questionnaire for All Health Policy Form Filings.Responsible Executive Officer or Official Designee Required to Sign and Certify Answers Given.
Published:
2008
Description:
Questionnaire for All Health Policy Form Filings.Responsible Executive Officer or Official Designee Required to Sign and Certify Answers Given.
Form Number:
H-QUEST General Cover for H-Quest Form and Instructions
Title:
H-QUEST General Cover for H-Quest Form and Instructions
Published:
2008
Description:
The H-Quest Questionnaire is being required of insurers as part of the Life and Health Division’s review of selected types of health insurance policy forms filings. These questions represent additional information the Commissioner has recently directed his staff to gather with respect to proposed health insurance forms filings or changes in previously approved health forms filings.
Form Number:
H-QUEST Instructions for Completion of Form
Title:
H-QUEST Instructions for Completion of Form
Published:
2008
Description:
H-QUEST Instructions for Completion of Form
Form Number:
Insurance Policy Form, Advertising or Rate Filing Fees
Title:
Insurance Policy Form, Advertising or Rate Filing Fees
Published:
2008
Description:
Insurance Policy Form, Advertising or Rate Filing Fees
Form Number:
LH-IF-P1
Title:
Health Insurance Rate Informational Filing (LH-IF-P1)
Published:
2008
Description:
Health Insurance Rate Informational Filing (LH-IF-P1)
Form Number:
LH-T1-P1
Title:
Health Insurance Rate Increase Filing Transmittal Form
Published:
2009
Description:
Health Insurance Rate Increase Filing Transmittal Form. Page1.
Form Number:
LH-TI-P2
Title:
Health Insurance Rate Increase Filing Transmittal Form
Published:
2009
Description:
Health Insurance Rate Increase Filing Transmittal Form. Page 2.
Form Number:
Model Georgia State Continuation Coverage Election Notice
Title:
Model Georgia State Continuation Coverage Election Notice
Published:
2009
Description:
Model Georgia State Continuation Coverage Election Notice
Form Number:
PRA Cover Letter
Title:
PRA Cover Letter
Published:
2009
Description:
PRA Cover Letter
Form Number:
Provider Instructions
Title:
Provider Instructions
Published:
2009
Description:
Please use this Provider Complaint Form when Mailing your Insurance issues into the Department.
Form Number:
Rate Filing Transmittal Form
Title:
Life and Health Division Rate Filing Transmittal Form
Published:
2008
Description:
Life and Health Division Rate Filing Transmittal Form
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