016.06.02 Ark. Code R. § 042 - Form DMS-836 - Premium Notification; Form DMS-837 - Premium Payment Selection Form; Form DMS-838 - Correction of TEFRA Waiver Premium Information; Form DMS-839 - Premium Invoice and Statement of Account and DMS-2602 - Physician Assessment of Eligibility

Arkansas Department of Human Services

TEFRA Waiver Program

Premium Notification

Dear TEFRA Recipient:

This letter is notification of your TEFRA Waiver premium amount and the monthly payment options. You will also receive periodic Premium Invoice and Statement of Account forms.

Your monthly TEFRA waiver premium is (premium amount) . An initial payment for your first two months premium (for the months of XXX and XXX) is due upon receipt. Total amount due is _____________. Future payments will be made based on the payment option you select.

Your TEFRA Account Number is:___________________________________________

You will need to enter your TEFRA Account Number on the Premium Payment Selection Form and on personal checks and money orders. Make your check or money order payable to: TEFRA Premium Unit.

ENCLOSED ARE THE FOLLOWING:

1) TEFRA Waiver Program Premium Payment Selection form. You are asked to choose your method of future payments. Please complete this form and attach the appropriate documentation and return in the envelope supplied.

2) Pre-paid business reply envelope for your convenience in returning your initial payment and your TEFRA Waiver Premium Payment Selection form.

If you choose to pay by monthly bank draft, your bank account will be drafted on the first business day of each month. If you choose to pay by check or money order, you will be required to remit payments on a quarterly basis. You will receive a monthly Invoice and Statement.

The bank that will process premium payment checks and monthly bank drafts on behalf of DHS will charge $28.00 for check overdrafts and up to $5.25 for failed monthly bank drafts. These fees, if assessed, will be shown on the monthly Premium Invoice and Statement of Account form.

If you need assistance in completing the forms or if you have any questions please contact the TEFRA Premium Unit at their toll free number, 1-866-239 -9938.

Sincerely,

TEFRA Premium Unit

Arkansas Department of Human Services

TEFRA Waiver Program Premium Payment Selection Form

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ARKANSAS DEPARTMENT OF HUMAN SERVICES

TEFRA Waiver Program

Premium Invoice and Statement of Account

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ARKANSAS DEPARTMENT OF HUMAN SERVICES

TEFRA Waiver Physician Assessment of Eligibility

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Notes

016.06.02 Ark. Code R. § 042

12/12/2002