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Discount Medical Plan Organization (DMPO) Renewal Form

For the renewal period May 1, 2017 to April 30, 2018

Name of Discount Medical Plan Organization: _______________________________________________

DMPO’s Principal Office Address: ________________________________________________________

DMPO’s Web Site(s): __________________________________________________________________

Nebraska Company Code: _ _ _ _ _ _

FEIN: _ _ - _ _ _ _ _ _ _

$300 renewal fee made payable to the Nebraska Department of Insurance

Submit this renewal form to the Nebraska Department of Insurance no later than March 1, 2017. The

renewal form must include the $300 renewal fee and must be certified as true and complete by a corporate

officer, partner, owner, or other duly authorized member of the DMPO. If the response to any question

below is “yes”, please provide details and attach the required explanation or documentation to this form.

Number of DMPO members in Nebraska?

Has the DMPO received any complaints from members or providers in the past year? If yes,

Yes No

please provide a complaint log stating each complainant’s name, date and nature of complaint,

and resolution including the basis for any denial of benefits. The complaint log should be

signed by the DMPO’s compliance officer.

Has there been any change to the list of names and address of the persons responsible for the

Yes No

conduct of the DMPO’s affairs (to include a compliance officer) including disclosures of the

extent and nature of any contracts or arrangements with such persons and the DMPO,

including any conflicts of interest, since the DMPO last provided this information?

Have any of the persons responsible for conduct of the DMPO’s affairs, including all

Yes No

corporate officers, been charged with or convicted of a crime? “Crime” includes a

misdemeanor, felony or military offense. If yes, provide a certified copy of the charging

document and any resolution of the charges, with a written explanation of the circumstances.

Have the DMPO and/or affiliates had an application for registration or licensure denied or a

Yes No

certificate of registration or license revoked, suspended, or terminated?

Has the DMPO and/or persons responsible for conduct of the DMPO been sued by any entity

Yes No

in any jurisdiction in the past five years, or has the DMPO and/or affiliates been investigated

for or found in violation of any statute or regulation?

Was the DMPO at any time unable to fully pay when due any debts or other obligations?

Yes No

Has the listing of health care providers currently under contract changed?

Yes No

I hereby certify that the information contained in this annual report and attachments is true and complete.

___________________________________

____________________________

_____________

Name and Title

E-mail Address

Date

___________________________________

Signature

Discount Medical Plan Organization (Dmpo) Renewal Form - Nebraska Department Of Insurance

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