INSTRUCTIONS: CONNECTICUT MEDICAL DISCOUNT PLAN (MDP) LICENSE RENEWAL

To apply for a renewal of a Connecticut medical discount plan (MDP) license, use the form discussed in this article. This document can be obtained from the website of the government of Connecticut.

Connecticut Medical Discount Plan (MDP) License Renewal Step 1: The first page contains general instructions.

Connecticut Medical Discount Plan (MDP) License Renewal Step 2: On the first blank line of the second page, enter the calendar year for which you are filing.

Connecticut Medical Discount Plan (MDP) License Renewal Step 3: On the second blank line, enter the name of the MDP.

Connecticut Medical Discount Plan (MDP) License Renewal Step 4: On the third blank line, enter all names used to market the MDP plan.

Connecticut Medical Discount Plan (MDP) License Renewal Step 5: On the fourth blank line, enter the MDP connecticut license number.

Connecticut Medical Discount Plan (MDP) License Renewal Step 6: On the fifth blank line, enter the MDP tax identification number or federal employer identification number.

Connecticut Medical Discount Plan (MDP) License Renewal Step 7: On the next three blank lines, enter the business address of the MDP.

Connecticut Medical Discount Plan (MDP) License Renewal Step 8: If your mailing address is different from your business address, enter it on the next two blank lines.

Connecticut Medical Discount Plan (MDP) License Renewal Step 9: On the eleventh blank line, enter the MDP phone number.

Connecticut Medical Discount Plan (MDP) License Renewal Step 10: Indicate with a check mark whether any suspension, sanction or disciplinary action has been taken against the MDP in any state. If yes, explain.

Connecticut Medical Discount Plan (MDP) License Renewal Step 11: Indicate with a check mark whether any suspension, sanction or disciplinary action has been taken against the controlling company or organization in any state. If yes, explain.

Connecticut Medical Discount Plan (MDP) License Renewal Step 12: At the top of the third page, enter the total number of enrollees served by the plan both nationwide and in Connecticut.

Connecticut Medical Discount Plan (MDP) License Renewal Step 13: List all provider networks with which the MDP has contracts or agreements to provide discounted health services to Connecticut enrollees.

Connecticut Medical Discount Plan (MDP) License Renewal Step 14: Complete the rest of the form as instructed.