Federal Employees Health Benefits Program
Statement About Service Area Expansion
(ONLY COMPLETE IF YOU ARE PROPOSING A SERVICE AREA
EXPANSION)
We have prepared the attached service area expansion proposal according to the
requirements found in Part Two, Changes in Service Areas, of the Technical Guidance
for 2002 Benefits and Service Area Proposals. Specifically,
1. All provider contracts have hold harmless provisions in them.
2. All provider contracts are fully executed at the time of this submission. I
understand that letters of intent are not considered contracts for purposes of this
certification.
3. All of the information provided in response to Part Two, Paragraph C, Access to
providers, is accurate as of the date of this statement.
___________________________________________________
Signature of Plan Contracting Official
___________________________________________________
Title
___________________________________________________
Plan Name
___________________________________________________
Date
