New York State seal

February 6, 1978

SUBJECT: INSURANCE

WITHDRAWN

Circular Letter NO. 4

FEBRUARY 6, 1978

To: ALL ACCIDENT AND HEALTH INSURERS, EXCLUDING ARTICLE IX-C CORPORATIONS, LICENSED IN NEW YORK STATE

RE: STANDARD CLAIM FORMS FOR ACCIDENT AND HEALTH INSURANCE

Chapter 545 of the Laws of 1977 provides that on or before January 1, 1979, the Superintendent of Insurance shall establish standard claim forms for the services of hospitals, physicians and other health providers to be used for all accident and health insurance claims filed with commercial health insurers. Prior to the establishment of the standard claim forms, the Superintendent, according to Chapter 545 of the Laws of 1977, is to investigate and review claim forms currently utilized by insurance carriers and providers of medical services.

As part of the Superintendent's investigation of currently utilized claim forms, it is requested that you forward copies of one hospital, one medical and one dental claim form now in use by your company which you consider to be the most widely accepted and efficient forms.

In addition to sending the claim forms mentioned above, your comments and suggestions concerning the implementation of Chapter 545 of the Laws of 1977 would be appreciated. Your claim forms and comments should be sent, no later than March 1, 1978, to:

James W. Clyne

Deputy Superintendent

NYS Insurance Department

Agency Building One

Empire State Plaza

Albany, New York 12223

Very truly yours,

[SIGNATURE]

ALBERT B. LEWIS

Superintendent of Insurance