Fillable Regulation 1316 Form C Proof of Service of (Department of Technology and Information)

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Regulation 1316 Form C Proof of Service of (Department of Technology and Information)

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U.S.A. forms for Department of Technology and Information

BROWSE DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) FORMS

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Regulation 1316 – Form C
Proof of Service of Papers Required for Non-Network Providers of Emergency Care
Services Health Care Reimbursement for Emergency Care Arbitration
I certify that on the ________ day of __________________, 20____, in addition to the
filing provided by the Insurance Commissioner, I sent a copy of the
______ Petition for Arbitration with required attachments
______ Response to the Petition for Arbitration with required attachments
______ Other (please describe) _______________________________________
__________________________________________________________
to the following person(s) by:
______ Certified mail, return receipt requested
______ First-class mail, postage-prepaid
Name
Address
Name
Address
Name
Address
The following is required by the person making this certification:
Name of Party
Address of Party
Signature of Party
NOTE: Save all proofs of mailing and return receipt(s) for verification by the Arbitrator.
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Regulation 1316 Form C Proof of Service of (Department of Technology and Information)

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Completed 27 January 2021

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