IDL 64-RIB (Page 1of 2) - Pennsylvania Insurance Department



COMMONWEALTH OF PENNSYLVANIAINSURANCE DEPARTMENTPharmacy Audit Integrity and Transparency Act Renewal FormPlease complete form and mail with check for $35.00 made payable to the “Commonwealth of Pennsylvania” to:Pennsylvania Insurance DepartmentCompany Licensing Division1345 Strawberry SquareHarrisburg, PA 17120 (717) 787-2735Type or Print ClearlyIDENTIFICATIONNOTE: Registration is required for each unique Employer Identification Number.Employer Identification Number: FORMTEXT ??- FORMTEXT ????Select One: FORMCHECKBOX Pharmacy Benefit Manager FORMCHECKBOX Auditing EntityFull Legal Name of Applicant: FORMTEXT ?????Mailing Address: FORMTEXT ?????Street (Required)(If applicable, include P.O. Box) FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????CityStateZip CodeBusiness Address: FORMCHECKBOX Same as mailing address FORMTEXT ?????Street (Required)(If applicable, include P.O. Box) FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????CityStateZip CodeApplicant Main Telephone Number: ( FORMTEXT ???) FORMTEXT ??? - FORMTEXT ????CONTACT PERSONFull Legal Name of Contact Person: FORMTEXT ?????Title of Contact Person: FORMTEXT ?????Business Telephone Number: ( FORMTEXT ???) FORMTEXT ??? - FORMTEXT ????Business Email Address:: FORMTEXT ?????SIGNATURE_________________________________________________Authorized Representative Signature FORMTEXT ?????_________________________________________________Authorized Representative Name (print or type) FORMTEXT ?????_________________________________________________Authorized Representative Title (print or type) FORMTEXT ????? FORMTEXT ?????______________ ______________Original Registration Date (print or type) Current Date FORMTEXT ?????_______________________Payment Check No. (print or type) ................
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