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Department of Insurance, Securities and Banking


E.g., 04/18/2024
E.g., 04/18/2024

Rector Report as part of Surplus Review and Determination Regarding Group Hospitalization and Medical Services, Inc.

These directions provide a general explanation of the information that you need to add to sections of the form.

Complete and return the license application form with the required attachments. For an initial registration to be complete, all of the required information must be included. An incomplete and incorrect application will result in the return of your application and possible denial.

This form is designed to authorize the disclosure of mental health information listed below by the individual practitioner to determine entitlement of paymant of claims or reimbursement.  It is not to be used for in-patient or partial hospitalization.

Initial application for written consent to engage in the business of insurance in the District of Columbia pursuant to 18 USC section 1033 and 1034


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