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Rhode Island Executive Office of Health and Human Services
Appeals Office, 74 West Road, Hazard Bldg., 2nd floor, Cranston, RI
02920 phone: 401.462.2132 fax: 401.462.0458
1
66 March 27, 2017 Docket # 17-35 Hearing Date: March 9, 2017
xxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxx ADMINISTRATIVE
HEARING DECISION The Administrative Hearing that you requested has
been decided in your favor. During the course of the proceeding,
the following issue(s) and Agency regulation(s) were the matters
before the hearing: RULES AND REGULATIONS PERTAINING TO THE RHODE
ISLAND HEALTH BENEFITS EXCHANGE (RIHBE) SECTION 4.0-Initial Open
Enrollment, Annual Open Enrollment, and Special Enrollment RHODE
ISLAND Policy Manual Chapter 9: Individual Eligibility and Shop
Appeals C. Appeals Process Rules, 17) Decisions CHAPTER 3: Open
Enrollment Periods, Special Enrollment Periods & Enrollment
Effective Dates C. Special Enrollment Periods The facts of your
case, the Agency regulations, and the complete administrative
decision made in this matter follow. Your rights to judicial review
of this decision are found on the last page of this decision.
Copies of this decision have been sent to the following: You (the
Appellant), and Health Source RI (HSRI) Agency representatives:
Lindsay Lang Esq., Ben Gagliardi Esq., and Derek Tevyaw. Present at
the hearing were: You (the Appellant), and Health Source RI (HSRI)
Agency representative: Ben Gagliardi, Esq. ISSUE: Should the
appellant be allowed enrollment in health coverage through HSRI
after closure of the 2017 open enrollment period?
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RIHBE RULES AND REGULATIONS/AND RI POLICY MANUAL: Please see the
attached APPENDIX for pertinent excerpts from the Rules and
Regulations Pertaining to the Rhode Island Health Benefits Exchange
and from the RI Policy Manual. APPEAL RIGHTS: Please see attached
NOTICE OF APPELLATE RIGHTS at the end of this decision. DISCUSSION
OF THE EVIDENCE: The Health Source Rhode Island (HSRI)
representative testified:
Appellant was eligible for Medicaid during 2016 and was
terminated during the month of December 2016.
She did contact HSRI on 12.29 and her eligibility was run at
that time and it was determined that she was eligible for $497.95
in tax credits based upon her reported income
A benefits decision notice was generated on 12.29 with the
information which allowed her to enroll in coverage up to January
31, 2017.
No plan was selected, and no payment was received and
accordingly coverage was not effectuated and remains inactive
because no plan or selection was ever made.
The coverage begin date on the notice indicates a January 1 date
but no plan was selected.
A summary of a December 12th call indicates the appellant called
to verify income, and she believes she has Medicaid.
There is a December 29th call which indicates that customer
thought she was Medicaid eligible
For Aid pending she would have had to have chosen a plan and
been already enrolled.
The appeal we are specifically here for today is that the client
states she cannot afford coverage and wants more tax credits.
We checked the numbers again based upon the income reported, and
it is our position that the initial numbers were correct and that
we did not make a mistake and the appellant could and should have
signed up for coverage based upon the information and during the
allotted window.
There is no open enrollment period or special enrollment period
allowed at that
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time.
There is a January 3rd call in which the client states she
cannot afford coverage and would like more tax credits to help her
pay for her plan.
There is no indication based upon his review that the Agency was
misleading and that there would be a change in tax credits or that
plan selection was indefinite.
All the same rules apply to all Rhode Islanders with respect to
plan costs and how much tax credits you are entitled to.
The appellant testified:
She was told she had Neighborhood Health, and she called and
called, and was told they would find out if she could lower the
payment from $71.00 and that she would have to go through an appeal
to do so.
She did receive multiple calls, and they continued to tell her
they were working on it.
She tried to explain her circumstances, and they said they
couldn’t do anymore and that is why I would have to go to
appeal.
She believes they told her they were working on it, and she is
still waiting.
Yes, she is not appealing Medicaid eligibility after the
discussions, but she does believe that HSRI stopped her from
applying for coverage.
She attempted to go through the automated on-line thing
initially in early January, and she kept hitting a wall and finally
she called HSRI.
They told her she could not stay in the Medicaid and she was
told she had to go on the health insurance, but because of the
amount she thought she had to go through the appeal to get a
different amount.
She never picked a plan because she thought she had to wait for
the appeal, and she is still waiting to see what the price of the
plan is.
SUMMARY OF PHONE CALLS (UNKNOWN AMOUNT OF TIME ON HOLD PRIOR TO
RECORDING/DATE OF CALL UNKNOWN-NEAR Jan. deadline…) 1st phone call:
About 1 hr. 25minutes 1st representative-The appellant contacts
HSRI and informs them she is going from Anchor (Medicaid coverage)
to regular medical (QHP) and she does not know what to pay, or how
much to pay. She states she has called about 8 times already
and
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someone begins to speak to her and she gets disconnected. She
has at least 4 disconnects. She states she is concerned about the
imminent loss of coverage on Saturday (Dec.31). She reports
continued automated calls which tell her to call back, and when she
does she hears voices in the background, and then is disconnected
again. The representative suggests putting the appellant through to
billing because perhaps they have her in a plan. The appellant
states she does not “even know what insurance she is getting.” The
appellant is placed on hold for one hour, and a second
representative comes on the line. 2nd representative-The appellant
informs the representative she is going from Anchor to regular
insurance, and does not yet have insurance. She repeatedly
throughout the conversation requests that she not be put on hold
due to the numerous disconnects. The appellant is put on mute for a
brief period, and the representative tells the appellant she should
not have to pay insurance because she is on Medicaid. The appellant
informs her she was told that she is no longer Medicaid eligible
and she had to go through HSRI. The representative investigates and
states yes the appellant is eligible for a QHP. The representative
informs the appellant she will be getting either Blue Cross or
Neighborhood. She asks about income and eligibility, and runs an
application. She informs the appellant of the amount of tax credits
to assist, and then informs her of the lowest cost plan. The
appellant states she cannot afford a plan that is that high. The
representative verifies the information again, and speaks to
herself about the high cost of plan. She then informs the appellant
that if nothing has changed financially since last year’s coverage,
she should still be eligible for Medicaid. The appellant informs
her she doesn’t mind paying something for her plan. The
representative verbally informs the appellant while she is writing
a ticket, “nothing has changed on her account. It’s telling me
she’s on QHP but she should be on Medicaid.” The representative
informs the appellant she will be placed in an escalation to get
her into Medicaid. The appellant will be contacted almost
immediately. 2nd phone call: About 1 hour. 1st representative-The
appellant contacts HSRI and informs she is calling because HSRI is
trying to put her on Medicaid. She has called back because she
received an automated call telling her to call back. She is put on
hold for 30’. 2nd representative-The appellant tells the
representative HSRI is trying to figure out whether she can stay on
Medicaid or whether she can pay a different amount of money. The
representative puts her on mute for 10’ and then tells her she is
not eligible for Medicaid, and she is qualified for the insurance
at the lowest cost of $71.36. The appellant repeatedly informs the
representative she will not be able to afford the plan. The
representative tells her that is the bottom price and cannot be
changed. The appellant asks what she should do because she is
stuck. The representative then asks to put her on hold. After 10’
she returns and tells the appellant she can appeal the decision and
possibly the Agency could give her a “little more tax credits to
help you pay.” The appellant asks how to complete an appeal, and
she is put on hold, and then is asked to wait for a call back from
a Supervisor to assist with the appeal. FINDINGS OF FACT:
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In a December 29, 2016 telephone call between HSRI and the
appellant, the appellant informs the Agency that although she is
told to pay a bill, she does not know what insurance she is getting
or what the cost is. She believes she is no longer eligible for
Medicaid. The Agency runs her application for eligibility and she
is determined QHP eligible. After discussing the high cost of the
plan, the representative informs the appellant she will put in for
an immediate escalation as the appellant should be in Medicaid if
her finances have not changed. The appellant agrees to wait for a
response.
A second phone call between HSRI and the appellant takes place
shortly after the first call (date unknown). During this call the
representative informs the appellant she is not eligible for
Medicaid and the lowest price plan is $71.36. The appellant states
she just cannot afford this amount. The representative informs her
that is the bottom line and the amount cannot be changed. The
appellant asks what her options are-she’s “stuck.” The
representative asks the appellant to wait a moment, and upon
return, informs the appellant that there is an option available to
her which is to appeal the decision (for emphasis) and perhaps the
Agency could give her a “little more tax credits to help you pay.”
The appellant is transferred to a Supervisor, and after a wait, is
asked to wait for a call back from the Supervisor to assist with an
appeal.
The Agency recommended the appellant appeal the decision in
order to decrease her premiums-which she did on December 29,
2016.
The appellant could not technically appeal a “decision” as
recommend by the Agency because the appellant never signed up for
coverage and there was never an eligibility decision rendered by
the Agency which informed her of the cost of the plan.
A December 29, 2016 Benefit Decision Notice received on or about
January 3rd or later, informs the appellant that tax credits will
be $497.95, and that plan payment and selection must be implemented
by January 31, 2017 in order to ensure health coverage before
January 31, 2017.
Upon receipt of the 12.29.16 notification above, the appellant
believes she is in a plan as she has already appealed the cost of
that plan as recommended by HSRI.
A hearing was held on March 9, 2017.
The record was held open until March 17, 2017 for additional
evidence.
Additional telephone conversations were submitted by HSRI; and,
the appellant was allowed access to the tapes at HSRI/and or
through the appeals office.
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CONCLUSION: The issue to be decided is whether the appellant
should be allowed enrollment in health coverage through HSRI after
closure of the 2017 open enrollment period? There is no dispute
that the appellant did not sign up for 2017 health insurance
coverage and did not pay for health coverage prior to completion of
the open enrollment period on January 31, 2016. Exploration of
RIHBE regulations and policies requires both health plan choice,
and payment prior to receipt of initial enrollment in any given
coverage year. HSRI establishes the open enrollment period which in
this case ended on January 31st. The December 29th Benefit Decision
Notification (received on or about January 3rd) informed the
appellant she needed to pick and pay for a plan prior to January
31, 2017. The Agency presents that the appellant was Medicaid
eligible in 2016 and was terminated in December 2016. They further
present that eligibility was run during a 12.29 phone call and the
appellant was determined eligible for $497.95 in tax credits. A
benefits decision notice was generated on 12.29 informing the
appellant that she could enroll in coverage up through January
31st. The Agency notes that the appellant represented in the
December 29th phone call that she thought she was Medicaid
eligible. They also contend that the appellant stated she could not
afford coverage and wanted more tax credits. They further argue
that the appeal is specific to the inability of the appellant to
afford coverage and the amount of the tax credits. After re-running
the numbers the Agency argues the appellant should have signed up
for coverage based upon the information given, and the allotted
open enrollment period. Because she did not enroll at that time she
is no longer eligible for enrollment. The appellant argues that she
made many calls to HSRI prior to the December 29th call as well as
the calls on that day. She testified that she understood she had
Neighborhood Health insurance and that through her appeal she was
attempting to determine whether or not HSRI could lower her
payment. She received multiple calls and thought that HSRI
continued to work on her issues, and she continues to wait. She did
attempt to sign up herself in January on line, but finally she
contacted HSRI by phone because of the ongoing online difficulties.
She believes HSRI stopped her from applying for coverage because
she thought she needed to wait to see what the price of the plan
was through the appeal, in order to pay for that plan. The
appellant gave credible testimony that she had attempted to contact
HSRI several times prior to the December 29th conversations. During
the two phone calls and four hours of conversations on that day
alone, the appellant spoke with a minimum of 5 representatives, and
was finally referred to another representative to complete her
appeal. The appellant began each phone call informing the
representatives she kept getting notices telling her to pay, but
she did not know how much the plan was and that she was going from
Anchor (Medicaid) to regular medical. During her initial call
eligibility
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was run and she was found to be QHP eligible. She expressed
concern about the high cost of the plan. Although the
representative had run the current numbers herself, she determined
that the system was wrong because the appellant should continue to
be eligible for Medicaid based upon no changes from last year. She
informed the appellant that HSRI would override her date of
December 31st loss of coverage as noted in the notices, and they
would allow her an extension until January 3rd while they escalated
her account and attempted to rectify the mistake. The appellant
called HSRI back on the same day, as she had received an automated
call from HSRI which was unrelated to her current escalation. The
appellant states that HSRI is trying to work on her insurance and
that they are trying to decide if she can stay on Medicaid or come
up with a different amount. During this second call, after a thirty
minute wait, the appellant is informed that she is not Medicaid
eligible. She is quoted the price of the lowest cost plan. The
appellant repeatedly states she cannot afford that amount. The
representative initially informs the appellant that this is the
bottom price for the NHP plan and cannot be changed. The appellant
informs her she is “stuck”, and asks the representative what she
should do. The representative tells the appellant she will put her
on hold. When she returns, she tells the appellant, “Ok, you can
appeal the decision and see if you can get more tax credits to help
you pay.” The appellant appeals and testifies that she is still
waiting to see if they can reduce her premium amount. In actuality,
she has no premium amount because she never signed up for the
insurance. The HSRI recordings in particular show an ongoing
confusion for both the appellant and the HSRI representatives with
regard to the course of events. Each of the representatives
recommends a different plan of action for the appellant although
the appellant informs each of them that she is switching from
Medicaid to regular insurance and needs to determine what to pay.
The first representative suggests a referral to billing, and places
the appellant on hold for 60”. The second representative runs the
current financial information, determines eligibility for a QHP,
but overrides the information before her. She informs the appellant
she can disregard the December 31st deadline for loss of coverage
and an extension will be allowed until January 3rd while HSRI
escalates the account because the appellant should have been found
Medicaid eligible. The third representative places the appellant on
hold for 30” and the fourth representative re-runs eligibility. She
informs the appellant that she is QHP eligible, that the lowest NHP
plan cost is $71.36, and that this is the bottom line and cannot be
changed. The appellant repeatedly informs the rep. she cannot
afford this amount, and she is “stuck.” She asks the representative
what she should do. The representative tells her to wait one
minute, returns, and offers her the appeals process. The appellant
then, does not complete enrollment in a plan, but appeals. The
appellant gives credible testimony that the events above influenced
her non-enrollment. In fact, the appellant never signed up for a
plan, and never receives an eligibility decision, but is offered an
appeal of that decision. She gave credible testimony that she
believed she had insurance, and that HSRI was working on reducing
the amount of the premium. It does not make sense that the
appellant could appeal a premium which she did not yet have. Thus,
the Agency was wrong in recommending that course of action at that
time. The subsequent December 29th notice informs the appellant she
must sign up for a plan by
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January 31st. By this time the appellant has already obtained a
new option from HSRI-her appeal of her plan price-and she has taken
that course of action. Review of the course of events shows that
the appellant made numerous calls to obtain QHP coverage. She makes
a good faith effort to communicate her situation to HSRI and is
given discrepant and erroneous information during several lengthy
phone calls and through numerous representatives and through
several call backs. It is highly believable that her non-enrollment
is unintentional and is the direct result of the ongoing
interactions with HSRI. When asked what she should do, the
appellant is not told she must enroll at the price given or lose
her opportunity for 2017 coverage; but, instead she is told she can
accept the option of an appeal. Consequently, the appellant never
completed her enrollment and waited for the reduction in the price
of a plan which she did not have. In summary, credible testimony
and evidence for the appellant showed that she made a good faith
attempt to enroll in coverage in 2017. Although she disputed with
HSRI the cost of the lowest price plan, her non-enrollment was
related to her understanding that her appeal would allow her to
formally dispute the amount of her plan. This was an incorrect
assumption both on her part and on the part of the HSRI
representative who assisted her, as she could not appeal the cost
of the plan because she was never in a plan. Confusing
recommendations by HSRI while providing enrollment assistance
clearly prevented the appellant from making a final decision about
enrollment. As a result of the misinformation by HSRI the appellant
will now be allowed to enroll in health coverage for the 2017 year.
Her request for relief is granted. After a careful review of the
Agency’s regulations and the testimony and evidence submitted, the
Appeals Officer finds that the appellant’s request for relief is
granted. ACTION FOR THE AGENCY: The Agency is to allow the
appellant retroactive coverage as of January 1, 2017; or, she may
choose to obtain coverage prospectively on the first day of the
month following this decision-April 1, 2017. Karen Walsh Appeals
Office
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APPENDIX
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RULES AND REGULATIONS PERTAINING TO THE RHODE ISLAND HEALTH
BENEFITS EXCHANGE Section 4.0 Initial Open Enrollment, Annual
Open Enrollment, and Special Enrollment Periods
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RHODE ISLAND POLICY MANUAL CHAPTER 9: INDIVIDUAL ELIGIBILITY AND
SHOP APPEALS C. Appeals Process Rules 17) Decisions The appeal
decisions must be written and based exclusively on relevant
evidence provided during the course of the appeal, including during
the hearing, and applicable law. Decisions must:
State the decision, including a plain language description of
its effect on an appellant’s eligibility;
Summarize the facts relevant to the appeal;
Identify the legal basis for the decision, including the
regulations that support it and any and all conclusions of law;
State the effective date of the decision; and
Explain the customer’s right to pursue an appeal with HHS if he
or she remains dissatisfied with the APTC/CSR eligibility
determination.54 EOHHS will issue the written notice of the appeal
decision to the customer within 30 days,55 but in no case shall
exceed 90 days of the appeal request “as administratively
feasible.”56 EOHSS must make the appeal record or decisions, as
relevant, accessible to the customer at a convenient place and
time, and must also provide public access to all appeal records or
decisions subject to applicable federal and state privacy and
confidentiality laws, which will require redactions of personal
information where appropriate.57 EOHHS will ensure that appeal
records or decisions, as relevant, are made available to the
appellant or the public upon request and in hard copy or
electronically.58
______________________________ 50 OHHS Code of Rules § 0110.55.
51 45 CFR 155.540(a); 42 CFR 431.244. 52 45 CFR 155.540(b); 42 CFR
431.244(f)(3) 53 Appeals Operations Manual, Rhode Island Unified
Health Infrastructure Project, Draft v 1.0 (July 26, 2013) at 12.
54 45 CFR S. 155.545(a), also OHHS 0110.60 55 OHHS Code of Rules §
0110.45.
In the SHOP Exchange, the appeal record must be accessible to
employers for an employer appeal. The appeal record must be
accessible to both employers and employees for employee appeals.59
Confidential information will be redacted and SHOP appeals will not
be publicly available.60 Decisions will be disseminated in writing
to the following people and agencies, dependent upon the program
eligibility of the customer:
Appellant
Authorized Representative, if assigned
DHS Field Worker
DHS Casework Supervisor
DHS Regional Manager
EOHHS Policy Office
Associate Director, Division of Medical Services (only in cases
when the Medicaid decision was in favor of the appellant)
HealthSource RI Legal Counsel and Appeals Team61
Employer in the case of an employee appeal in the SHOP
Exchange.62 Any decision in favor of the individual shall
apply:63
Prospectively, on the first day of the month following the date
of the notice of appeal decision, or consistent with
§155.330(f)(2), (3), (4), or (5); or
Retroactively, to the date of the incorrect eligibility
determination was made, at the option of the appellant.
Additionally, if a decision is entered in favor of an individual,
HealthSource RI will redetermine the eligibility of household
members who have not appealed their own eligibility determinations
but whose eligibility may
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be affected by the appeal decision, in accordance with the
standards specified in§ 155.305.
CHAPTER 3: Open Enrollment Periods, Special Enrollment Periods
& Enrollment Effective Dates C. Special Enrollment Periods
Individuals and families may be eligible to enroll in a QHP through
Health Source RI outside of annual open enrollment as a result of a
qualifying event. There are nine categories of acceptable
qualifying events, including: 1) Loss of coverage. The qualified
individual or his or her dependent: a. Loses minimum essential
coverage;
b. Loses pregnancy-related coverage; or c. Loses medically-needy
coverage. In each of the circumstances described above, the
individual or his or her dependent has 60 days after the loss of
coverage to select a QHP.11 Loss of coverage does not include
voluntary termination, rescissions or failure to pay premiums on a
timely basis (including COBRA premiums prior to exhausting COBRA
coverage). 11 45 CFR 155.420(c). A special enrollment period under
this category may not begin prior to the date of the qualifying
event. Coverage will be backdated to the first of the month
following the loss of coverage. 12 In such cases, Health Source RI
may take such action to correct or limit the effects of the error,
misrepresentation or inaction. 13 In this circumstance, the
individual or dependent has 60 days after the loss of eligibility
in ESI coverage to select a QHP, retroactive to the first of the
month after month in which coverage ended under an eligible
employer-sponsored plan 2) Addition of a household member or
dependent. The qualified individual gains a dependent or becomes a
dependent through marriage, birth, adoption, placement for
adoption, placement in foster care or as the result of a child
support order or other court order.
3) Change in Lawful Status. The qualified individual, or his or
her dependent, gains status as a citizen, national, or lawfully
present individual.
4) Enrollment Error by Health Source RI’s Determination. The
qualified individual's or his or her dependent's, enrollment or
non-enrollment in a QHP is unintentional, inadvertent, or erroneous
and is the result of the error, misrepresentation, misconduct, or
inaction of an officer, employee, or agent of Health Source RI, its
instrumentalities, or a non-Exchange entity providing enrollment
assistance or conducting enrollment activities.12
5) Substantial Violation. The enrollee or, his or her dependent
adequately demonstrates to HealthSource RI that the QHP in which he
or she is enrolled substantially violated a material provision of
its contract with the enrollee.
6) IAP Eligibility. The individual or dependent enrolled in a
QHP or an eligible employer-sponsored plan becomes newly eligible
or ineligible for advance payments of the premium tax credit
(APTC), or experiences a change in eligibility for cost-sharing
reductions.13
7) Permanent Move. The qualified individual or enrollee, or his
or her dependent, gains access to new QHPs following a permanent
move.
8) American Indian Status. The qualified individual who is an
Indian, as defined by Section 4 of the Indian Health Care
Improvement Act, may enroll in a QHP or change from one QHP to
another one time per month;
9) Exceptional Circumstances. The qualified individual or
enrollee, or his or her dependent, demonstrates to Health Source
RI, in accordance with guidelines issued by HHS, that the
individual meets other exceptional circumstances as Health Source
RI may provide.
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NOTICE OF APPELLATE RIGHTS This Final Order constitutes a final
order of the Department of Human Services pursuant to RI General
Laws §42-35-12. Pursuant to RI General Laws §42-35-15, a final
order may be appealed to the Superior Court sitting in and for the
County of Providence within thirty (30) days of the mailing date of
this decision. Such appeal, if taken, must be completed by filing a
petition for review in Superior Court. The filing of the complaint
does not itself stay enforcement of this order. The agency may
grant, or the reviewing court may order, a stay upon the
appropriate terms. This hearing decision constitutes a final order
pursuant to RI General Laws §42-35-12. An appellant may seek
judicial review to the extent it is available by law. 45 CFR
155.520 grants appellants who disagree with the decision of a State
Exchange appeals entity, the ability to appeal to the U.S.
Department of Health And Human Services (HHS) appeals entity within
thirty (30) days of the mailing date of this decision. The act of
filing an appeal with HHS does not prevent or delay the enforcement
of this final order. You can file an appeal with HHS at
https://www.healthcare.gov/downloads/marketplace-appeal-request-form-a.pdf
or by calling 1-800-318-2596.
https://www.healthcare.gov/downloads/marketplace-appeal-request-form-a.pdfhttps://www.healthcare.gov/downloads/marketplace-appeal-request-form-a.pdf