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Form Instructions 843 College Station Texas: What You Should Know

This acknowledgment may be made under penalties of perjury. (h) The health professional may not provide financial assistance to you for the cost, incurred under this chapter, of any claim that arose during the period beginning on August 21, 2014, and ending on the date the application is filed. No certificate of authority may be issued or renewed in the name of your health plan, self-insured employer, or health maintenance organization until this requirement is met. (Added by Stats. 2013, Ch. 811, Sec. 5. (AB 641) Effective January 1, 2014.) SEC. 4. (a) In this chapter “medical device” means any device which is implanted, manufactured, or modified, or any other apparatus, instrument, implant, implant-type device, or other similar item that is used, or that is intended for use or that can be readily restored to use, to diagnose, treat, or prevent disease, disorder, abnormality, injury, or impairment of physical or mental functions, or that is intended for use or that can be readily restored to use in a medical or surgical setting for this purpose.  (b) A prescription drug plan or prescription drug plan contract shall include, as a part of its definition of medical device, the following as a minimum: (1) A claim form that provides: (A) Notice that a prescription drug plan, other than a self-insured plan, may impose an administrative fee to be based on a claim as to each medical device. (B) The prescription drug plan's policy on the use of the administrative fee. (2) The amount of any fee assessed to a plan under Subdivision (9) that is not paid to the state treasurer. (3) The amount of any state and local government assessment imposed under Subdivision (10) for administrative costs in administering the claims process. (4) The name and address of the plan's attorney. (5) An explanation of the policy on the use of the administrative fee.

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