Notice Of Intent To Form A Managed Care Organization {2737}

Insert your company name Address Telephone number NOTICE OF INTENT TO FORM A MANAGED CARE ORGANIZATION To the Department of Consumer and Business Services: According to ORS 656.260(9) and OAR 436-015-0010, the people listed below provide notice that they have entered into discussions or negotiations with the intent to form a managed care organization (MCO). In doing so, we provide the department with the following information: 1) Those who will participate in dicussions intended to result in the formation of an MCO. If the person is a member of a closely held corporation, include the identity of the shareholders (attach additional pages as necessary): 2) Name, address, and phone number of a contact person for this Notice of Intent: 3) Summary of the information being shared during discussions preceding the application for MCO certification. (Provide information in a separate document and attach to this form.) Name: Signature: Title: Date: Send completed form and any attachments to: Department of Consumer and Business Services Workers' Compensation Division Managed Care Program/Medical Section P.O. Box 14480 Salem, OR 97309-0405 Questions? Call 503-947-7650 or 503-947-7697 440-2737 (1/12/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com