INSTRUCTIONS: CONNECTICUT PREFERRED PROVIDER NETWORK (PPN) LICENSE INSTRUCTIONS AND APPLICATION (RENEWAL)

To apply for a renewal of a license to act as a Connecticut preferred provider network (PPN), use the application discussed in this article. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Renewal) Step 1: The first page contains general instructions.

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Renewal) Step 2: Enter the name of the PPN on the first blank line of the second page.

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Renewal) Step 3: Enter the PPN license number on the second blank line.

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Renewal) Step 4: Enter the PPN tax identification number or federal employer identification number on the third blank line.

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Renewal) Step 5: Enter the PPN business address on the fourth blank line.

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Renewal) Step 6: Enter the PPN mailing address, if different, on the fifth blank line.

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Renewal) Step 7: Enter the PPN phone number on the sixth blank line.

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Renewal) Step 8: Answer the three questions on this page by filling in the oval next to "yes" or "no" as applicable. Note that if you answer either of the first two questions "yes," you are not required to complete this application.

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Renewal) Step 9: On the third page, answer the first question about whether any suspensions, sanctions or disciplinary actions have been taken against the controlling company or organization in the last 10 years in any state by filling in "yes" or "no" as applicable. If yes, provide an explanation.

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Renewal) Step 10: Enter a description of the PPN's service area.

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Renewal) Step 11: Enter the number of total enrollees served by the PPN both nationwide and in Connecticut.

Connecticut Preferred Provider Network (PPN) License Instructions And Application (Renewal) Step 12: Complete the rest of the application as instructed.