Va. Admin. Code tit. 1, agency 55, ch. 20, pt. V, form FORMS (1VAC55-20)

Current through Register Vol. 41, No. 10, December 30, 2024

Form - FORMS (1VAC55-20)

Adoption Agreement, T20082 (R1/02)

Commonwealth of Virginia Health Benefits Program Application, T20445 (rev. 1/13)

Enrollment Form - The Local Choice Health Benefits Program, T20911 (1/14)

General Notice of Extended Coverage Rights (rev. 3/05)

Interagency Transfer Invoice, Department of Accounts DA-02039 (rev. 7/86)

Commonwealth of Virginia Certificate of Group Health Plan Coverage and Statement of HIPAA Portability Rights (rev. 4/05)

State Health Benefits Program Appeal Form (rev. 5/11)

Va. Admin. Code tit. 1, agency 55, ch. 20, pt. V, form FORMS (1VAC55-20)

Amended, Virginia Register Volume 30, Issue 14, eff. April 24, 2014.

Statutory Authority: § 2.2-2818 of the Code of Virginia.