Authorized delegate reporting

(a) Each licensee shall submit a report of authorized delegates within forty-five (45) days after the end of the calendar quarter.

(b) The authorized delegate report must include, at a minimum, each authorized delegate's:(1) Company legal name;(2) Taxpayer employer identification number;(3) Principal provider identifier;(4) Physical address;(5) Mailing address;(6) Business conducted in other states;(7) Any fictitious or trade name;(8) Contact person name, phone number, and email;(9) Start date as licensee's authorized delegate;(10) End date acting as licensee's authorized delegate, if applicable; and(11) Any other information the commissioner reasonably requires with respect to the authorized delegate.

(1) Company legal name;

(2) Taxpayer employer identification number;

(3) Principal provider identifier;

(4) Physical address;

(5) Mailing address;

(6) Business conducted in other states;

(7) Any fictitious or trade name;

(8) Contact person name, phone number, and email;

(9) Start date as licensee's authorized delegate;

(10) End date acting as licensee's authorized delegate, if applicable; and

(11) Any other information the commissioner reasonably requires with respect to the authorized delegate.