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Arkansas Blue Cross and Blue Shield
Utilization Management Biographical Affidavit Additions
Please submit your answers by the end of the day on June 22, 2022.
First name
(Required)
Last name
(Required)
Have you been convicted of, or currently charged with, committing a misdemeanor or had a judgment withheld or deferred for a misdemeanor which has not been previously reported?
(Required)
Yes
No
Have you been convicted of, or currently charged with, committing a felony or had a judgment withheld or deferred for a felony which has not been previously reported?
(Required)
Yes
No
Have you been convicted of, or currently charged with, committing a military offense which has not been previously reported?
(Required)
Yes
No
Have you been named or involved as a party in an administrative proceeding, including a FINRA sanction or arbitration proceeding, regarding any professional or occupational license or registration which has not been previously reported?
(Required)
Yes
No
Do you have a child support obligation in which you are currently out of compliance?
(Required)
Yes
No
If the answer to any of the above questions is yes, please explain below.
(Required)