Fillable INDEPENDENT REVIEW ORGANIZATION RENEWAL FORM (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

Fill Online, Printable, Fillable, Blank INDEPENDENT REVIEW ORGANIZATION RENEWAL FORM (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor) Form

Use Fill to complete blank online MONTANA OFFICE OF THE COMMISSIONER OF SECURITIES AND INSURANCE, MONTANA STATE AUDITOR (MT) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

INDEPENDENT REVIEW ORGANIZATION RENEWAL FORM (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

On average this form takes 8 minutes to complete

The INDEPENDENT REVIEW ORGANIZATION RENEWAL FORM (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor) form is 4 pages long and contains:

  • 0 signatures
  • 16 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor

BROWSE MONTANA OFFICE OF THE COMMISSIONER OF SECURITIES AND INSURANCE, MONTANA STATE AUDITOR (MT) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
INDEPENDENT REVIEW ORGANIZATION
DEMOGRAPHIC INFORMATION
Business Name:
7D[,GHQWL¿FDWLRQ1XPEHU
BUSINESS CONTACT INFORMATION
0DLOLQJ$GGUHVV:
City/State/Zip:
6WUHHW$GGUHVV:
City/State/Zip:
%XVLQHVV7HOHSKRQH1XPEHU: %XVLQHVV)D[1XPEHU:
COMPLIANCE CONTACT INFORMATION
Name: Title:
7HOHSKRQH Email:
Matt M. Rosendale
&RPPLVVLRQHURI6HFXULWLHV,QVXUDQFH
0RQWDQD6WDWH$XGLWRU
840 Helena Ave. • Helena, MT 59601
3KRQHRU
)D[:HEZZZFVLPWJRY
INDEPENDENT REVIEW ORGANIZATION
RENEWAL FORM
This form is for entities seeking renewal of their two-year certification to serve in Montana as an independent review organization
(IRO). Pursuant to MCA § 33-32-416, an IRO must obtain the approval of the Office of the Montana State Auditor, Commissioner of
Securities and Insurance (CSI) to perform external review services. Please complete this form and attach any required
documentation. The CSI will contact your entity if we require any additional information. If you have any questions, please
contact David Dachs at: marketconduct@mt.gov or (406) 444-9722.
INSTRUCTIONS:
This form can be filled out and saved in Adobe Acrobat Reader. To download the lastest version of Adobe Reader for free, go to:
http://get.adobe.com/reader/. To submit this renewal form, please go to: www.csimt.gov/IROsubmit.
Please submit this form, and any changes to the following documentation:
Statement of disciplinary action, sanction, or consent
agreement or other settlement by or with any hospital,
government agency, government unit, or regulatory body
Statement identifying the areas of expertise for which
the applicant provides independent review, and the number of
reviewers meeting the qualication requirements of
MCA § 33-32-417 within each respective area of expertise
Fee Schedule
Copies of policies and procedures governing all aspects of
both the standard external review process and the expedited
external review process.
Document summarizing, for each policy or procedure,
the aspects of both the standard and external review processes
that the policy or procedure governs.
Mail $150 renewal application fee to 840 Helena Avenue,
Helena MT 59601. Direct Payment to the attention of Market
Conduct - IRO Renewal Application Fee.
Documentation of Accreditation
Yes
1R
ACCREDITATION
Were there any changes to your organization's previously reported accreditation
,I\HV
what changes"
APPLICANT/REVIEWER QUALIFICATIONS
'RHVWKHDSSOLFDQWSHUIRUPLQGHSHQGHQWH[WHUQDOUHYLHZVLQRWKHUVWDWHV"
Yes
1R
,I\HVLQZKDWVWDWHV"
+DVDVWDWHHYHUGHQLHGRUZLWKGUDZQDSSURYDOIRUWKHDSSOLFDQWWRSHUIRUPLQGHSHQGHQWH[WHUQDOUHYLHZV"
Yes
1R
+DVWKHDSSOLFDQWHYHUORVWRUEHHQWKUHDWHQHGZLWKORVLQJDFFUHGLWDWLRQWRSHUIRUPLQGHSHQGHQWH[WHUQDOUHYLHZV"
Yes
1R
+DVWKHDSSOLFDQWRUDQ\FOLQLFDOUHYLHZHUDVVRFLDWHGZLWKWKHDSSOLFDQWEHHQVXEMHFWWRDQ\GLVFLSOLQDU\DFWLRQVDQFWLRQ
RUFRQVHQWDJUHHPHQWRURWKHUVHWWOHPHQWE\RUZLWKDQ\KRVSLWDOJRYHUQPHQWDJHQF\JRYHUQPHQWXQLWRUUHJXODWRU\
ERG\"
If yes, please attach a statement providing details.
Please attach a document identifying any changes to the areas of expertise for which the applicant
provides independent review, or the number of reviewers meeting the qualification requirements of
MCA ZLWKLQHDFK respective area of expertise.
Please include documentation of any changes to your accreditation.
IN THE PAST TWO YEARS:
EXTERNAL REVIEW HOTLINE
'RHVWKHDSSOLFDQWPDLQWDLQDWROOIUHHWHOHSKRQHVHUYLFHWRUHFHLYHLQIRUPDWLRQUHODWHGWRH[WHUQDOUHYLHZVRQDKRXU
DGD\GD\DZHHNEDVLV"
Yes
1R
,I\HVLVWKHVHUYLFHFDSDEOHRIDFFHSWLQJUHFRUGLQJRUSURYLGLQJDSSURSULDWHLQVWUXFWLRQWRLQFRPLQJWHOHSKRQHFDOOHUV
GXULQJRWKHUWKDQQRUPDOEXVLQHVVKRXUV"
Yes
1R
,I\HVSURYLGHWHOHSKRQHQXPEHU
POLICIES AND PROCEDURES
0RQWDQD&RGH$QQRWDWHGUHTXLUHVDQLQGHSHQGHQWUHYLHZRUJDQL]DWLRQWRHVWDEOLVKDQGPDLQWDLQZULWWHQ
SROLFLHVDQGSURFHGXUHVWKDWJRYHUQDOODVSHFWVRIERWKWKHVWDQGDUGH[WHUQDOUHYLHZSURFHVVDQGWKHH[SHGLWHGH[WHUQDO
UHYLHZSURFHVV
FINANCIAL CONFLICT OF INTEREST
,VWKHDSSOLFDQWUHODWHGLQDQ\ZD\GLUHFWO\RULQGLUHFWO\WRDKHDOWKSODQKHDOWKLQVXUDQFHLVVXHUWUDGHDVVRFLDWLRQRI
KHDOWKSODQVRUWUDGHDVVRFLDWLRQRIKHDOWKFDUHSURYLGHUV"³5HODWHG´LQFOXGHVEXWLVQRWOLPLWHGWREHLQJRZQHGRUFRQ
WUROOHGE\RUEHLQJDVXEVLGLDU\RIRZQLQJRUH[HUFLVLQJFRQWURORYHURUEHLQJRZQHGE\WKHVDPHKROGLQJFRPSDQ\DVWKH
RWKHUSDUW\
Yes
1R
3OHDVHLGHQWLI\DOOKHDOWKSODQVRUKHDOWKLQVXUDQFHLVVXHUVIRUZKLFKWKHDSSOLFDQWFXUUHQWO\SURYLGHVH[WHUQDOUHYLHZV
Please provide a copy of the applicant’s fee schedule, if it has changed in the past two years.
Please attach copies of any changes to your organization's policies and procedures governing all aspects
of both the standard external review process and the expedited external review process.
For any changes, please attach a document summarizing, for each policy or procedure, the aspect or
aspects of external review processes that the policy or procedure governs.
RENEWAL FORM ATTESTATION AND CERTIFICATION
$SSOLFDQWKDVUHFHLYHGDFFUHGLWDWLRQDVDQLQGHSHQGHQWUHYLHZRUJDQL]DWLRQE\ DFFUHGLWLQJ
ERG\WRFRQGXFWLQGHSHQGHQWH[WHUQDOUHYLHZV$SSOLFDQWFHUWL¿HVWKDWLWZLOOQRWLI\WKH2I¿FHRIWKH0RQWDQD6WDWH$XGLWRU
&RPPLVVLRQHURI6HFXULWLHVDQG,QVXUDQFH&6,LIDFFUHGLWDWLRQLVORVWZLWKWKLVDFFUHGLWLQJERG\$SSOLFDQWDFNQRZOHGJHV
WKDW
WKH&6,PD\WHUPLQDWHWKLVOLFHQVHLIWKHDSSOLFDQWORVHVDFFUHGLWDWLRQRUQRORQJHUVDWLV¿HVWKHPLQLPXPUHTXLUHPHQWV
IRUOLFHQVXUH
$SSOLFDQWDFNQRZOHGJHVWKDWSD\PHQWRIDQ\IHHVDVVRFLDWHGZLWKDQ\H[WHUQDOUHYLHZVFRQGXFWHGWR0RQWDQD&RGH
$QQRWDWHG7LWOH&KDSWHUDUHWKHVROHUHVSRQVLELOLW\RIWKHKHDOWKLQVXUDQFHLVVXHUZKRVHGHFLVLRQLVEHLQJUHYLHZHG
$SSOLFDQWXQGHUVWDQGVWKDWLWKDVQRUHFRXUVHDJDLQVWWKH&6,RUWKH6WDWHRI0RQWDQDWRWKHH[WHQWWKDWDQ\KHDOWK
LQVXUDQFHLVVXHUIDLOVWRSD\DQ\PHGLFDOUHYLHZHUIHHV$SSOLFDQWDXWKRUL]HVWKH&6,WRYHULI\LQIRUPDWLRQZLWKDQ\IHGHUDO
VWDWHRUORFDOJRYHUQPHQWDJHQF\LQVXUDQFHFRPSDQ\RUDFFUHGLWLQJRUJDQL]DWLRQ
$SSOLFDQWDFNQRZOHGJHVDQGUHSUHVHQWVWKDWLWXQGHUVWDQGVDQGZLOOFRPSO\ZLWK0RQWDQD¶VLQVXUDQFHODZVLQFOXGLQJ
DSSOLFDEOHDGPLQLVWUDWLYHUXOHV$SSOLFDQWIXUWKHUDJUHHVWRPDLQWDLQDQGSURYLGHWRWKH&6,WKHLQIRUPDWLRQVHWRXWLQ0&$

,KHUHE\FHUWLI\WKDWXQGHUSHQDOW\RISHUMXU\,DPWKHSHUVRQQDPHGEHORZDQGNQRZWKHFRQWHQWVRIWKLVDSSOLFDWLRQDQG
WKDWDOORIWKHLQIRUPDWLRQVXEPLWWHGLQWKLVDSSOLFDWLRQDQGWKHDWWDFKPHQWVDUHWUXHDQGFRPSOHWH,DWWHVWWKDW,KDYHWKH
DXWKRULW\DQGFDSDFLW\WRH[HFXWHWKLVFHUWL¿FDWLRQRQEHKDOIRI$SSOLFDQW,DPDZDUHWKDWVXEPLWWLQJIDOVHLQIRUPDWLRQRU
RPLWWLQJSHUWLQHQWRUPDWHULDOLQIRUPDWLRQLQFRQQHFWLRQZLWKWKLVDSSOLFDWLRQLVJURXQGVIRUOLFHQVHGHQLDORUUHYRFDWLRQDQG
PD\VXEMHFWPHWRFLYLORUFULPLQDOSHQDOWLHV
1DPHRI$SSOLFDQW
(OHFWURQLF6LJQDWXUHRI2I¿FHURU5HSUHVHQWDWLYHRI$SSOLFDQW
3ULQWHGQDPH Title:
Date:
Matt M. Rosendale&RPPLVVLRQHURI6HFXULWLHV,QVXUDQFH
2I¿FHRIWKH0RQWDQD6WDWH$XGLWRU
840 Helena A
ve. • Helena, MT 59601
3KRQHRU
)D[:HEZZZFVLPWJRY
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

INDEPENDENT REVIEW ORGANIZATION RENEWAL FORM (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document