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Form Ins-Murl - Application For License As A Medical Utilization Review Entity - Insurance Department - New Hampshire Page 5

18.

I have read the foregoing application and attachments and state that the

answers supplied therein are true and correct to the best of my knowledge

and belief. The undersigned also acknowledges that all applicable state

and federal laws to protect the confidentiality of medical information will be

followed. Further, by submitting this application to the Insurance

Department, the applicant acknowledges that it has read and will comply

with the performance standards set forth in RSA 420-E and any applicable

rules.

Signed on behalf of the applicant by:

Name (Typed)

Title:

Date:

f:michele/urapplication.doc

Form Ins-Murl - Application For License As A Medical Utilization Review Entity - Insurance Department - New Hampshire Page 5