Carrier Application/Certification Form
Instructions: This form is required for all Qualified Health Plan (QHP) and Stand-Alone Dental Plan (SADP) applications.
Email address *
Carrier/Issuer’s Legal Name *
NAIC Number *
Date Maryland Licensure Received *
MM
/
DD
/
YYYY
Expiration Date of Maryland License *
MM
/
DD
/
YYYY
Federal Employer Identification Number *
Please enter EIN in XX-XXXXXXX format
HIOS Issuer Identification Number *
Street Address *
City *
State *
Zip Code *
Submitter’s Contact Name *
Submitter’s Contact Phone *
Do you have a TPA for processing enrollment? *
Do you have a TPA for processing claims? *
If you're using a TPA, please mention the TPA Name
Carrier/Issuer’s address for consumer’s payment submissions *
Carrier/Issuer’s payment guideline language for consumers *
Please use the upload document option available below if this space is not sufficient.
Upload payment guideline language documents
DOC, DOCX and PDF files only
Upload carrier's logo if has it changed
PDF and Image files only
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