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Form Instructions 843 Texas: What You Should Know

Thereafter, the plan application form should state that the form is a request for selection of a primary care provider (as defined by Sec. 843.207(a) or (b)(13) and/or, by State law, that the fee or other payment requested is for a physician or provider other than the primary care provider (as defined by Sec. 843.207(a) or (b)(13)) (i) selected by the plan and (ii) identified on the plan. (4)(b)(i) If the primary care provider is not a plan-sponsored payer, the plan shall, in the application form specify that the 1,180,000 no tax due threshold (See instructions for. (4)(b)(ii)). If the primary care provider (as defined by Sec. 843.207(a) and (b)(13)) is not the selected physician, the form shall state that the plan is asking the enrolled to choose a physician (as defined by Sec. 843.207(a)), and to specify the physician and physician's specialty. (4)(b)(ii) If the primary care provider is not a plan-sponsored payer, the plan shall, in the application form specify that the enrolled is free to select a physician (as defined by Sec. 843.207(a), or the primary care provider selected by the enrolled) (provided that the plan meets the requirements for using Form 843 (Form 1040A, 1040EZ, 1040S, 1040A-EZ, 1040S-EZ) as provided in Sec. Sec. 6025 of the Internal Revenue Code and applicable State law, and provided that the fee/other payment requested is for a physician or provider other than the primary care provider selected by the enrolled). (4) Each plan application form shall state, as applicable, whether the information about the physician selected by the enrolled is complete, correct, and timely; whether the enrollment information is complete, correct, and timely; whether information submitted via Form 843 (Form 1040A, 1040EZ, 1040S, 1040A-EZ, 1040S-EZ) is correct and timely; and whether the applicant has been provided information about the primary care provider's fees, including any cost-share imposed under the plan.

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