The following forms are to be used in conjunction with the rules adopted under this chapter. Copies of these forms may be obtained by contacting the Company Licensing and Registration Division, Mail Code 305-2C, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. Each HMO or other person or entity shall use such form or forms as are required by this title and as are appropriate to its particular activities. The forms are listed as follows:

1. (1) Name Application Form Rev. 02/99;
2. (2) Application for a Certificate of Authority to do business in the State of Texas, Rev. 02/99;
3. (3) State of Texas Officers and Directors Page, Rev. 06/2000;
4. (4) State of Texas Biographical Affidavit, Rev. 01/2002;
5. (5) HMO Certification and Transmittal Form Rev. 02/99;
6. (6) Reconciliation of Benefits to Schedule of Charges Form, Rev. 04/92;
7. (7) Deposit Report Form, No. 120; and
8. (8) Withdrawal Form, No. 121.

Source Note:The provisions of this §11.1001 adopted to be effective December 11, 1984, 9 TexReg 6807; amended to be effective December 4, 1987, 12 TexReg 4364; amended to be effective August 17, 1992, 17 TexReg 5360; amended to be effective November 2, 1998, 23 TexReg 11347; amended to be effective February 24, 2005, 30 TexReg 854.