28 CA ADC § 1300.51.1
28 CCR s 1300.51.1
Cal. Admin. Code tit. 28, s 1300.51.1
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 3. PLAN APPLICATIONS AND AMENDMENTS
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.51.1. Individual Information Sheet.
An individual information sheet required pursuant to these rules shall be
in the following form:
CONFIDENTIAL See Note to Item 5
DEPARTMENT OF MANAGED HEALTH CARE State of California INDIVIDUAL
INFORMATION SHEET under the Knox-Keene Health Care Service Plan Act of
1975 (California Health & Safety Code Sec. 1340 et. seq.) 1. Name of
Applicant: File No. ____________________
________________________________________ 2. Exact full name of person
completing this statement: __________ First Middle Last 3. Physical
Description: Sex______Hair______Eyes_______Height_______Weight______ 4.
Birthdate: __________________ Birthplace:__________________________ 5.
Social Security No. or Taxpayer Ident. No: __________
NOTE: The inclusion of your social security number is not required but is
voluntary. It is solicited pursuant to Sections 1344 and 1351 of the
Health and Safety Code. It may be used to conduct a background
investigation by the Department, the California Department of Justice
Information Branch, or by other federal, state or local law enforcement
agencies. This form, including the social security number, will be held
confidential, but is a public record and available to the public pursuant
to the Public Records Act (Gov. Code Section 6250), at the discretion of
the Director. 6. Residence Telephone: 7. Business Telephone: __________ 8.
Current Residence Address: __________ Number and Street City State Zip
9. Employment for the last 5 years (list most recent first and include any
employment with a plan or any person or entity which is or was affiliated
with a plan (Section 1300.45(c)):
From to Present Employer Name and Address Occupation and Duties
____________________________________________________________________
__________ __________ __________ __________ __________
NOTE: Attach separate schedule if space is not adequate. 10. Business
contacts, dealings and affiliations (see section 1300.45(c)(2)) with
health care service plans during the last 5 years (but including, for
example, such roles as director, stockholder, consultant, manager,
provider and supplier, and such dealings as sales, leasing, and any
contractual relationships) (list most recent business contacts and
dealings first):
From to Present Plan Name and Address Relationship and Duties
__________ __________ __________ __________ __________ __________
NOTE: Attach separate schedule if space is not adequate.
11. Have you ever had a certificate, license, permit registration or
exemption issued pursuant to the Business and Professions Code or Health
and Safety Code denied, revoked or suspended or been otherwise subject to
disciplinary action, while you were in the employ of the applicant, or
while you had a contract with the applicant as a provider or otherwise? [
] Yes [ ] No
If "yes" state the date of the action and the administrative body taking
such action.
__________ __________ __________ __________ __________ __________
12. Have you ever been convicted or pled nolo contendere to a misdemeanor
involving moral turpitude or any felony, other than traffic violations? [
] Yes [ ] No
If the answer is "yes" give details:
__________ __________ __________ __________ __________ __________
13. Have you ever changed your name or ever been known by any name other
than that herein listed? (Including a married person's prior surname, if
any.) [ ] Yes [ ] No
If so, explain. Change in name through marriage or court order should also
be listed. EXACT DATE OF EACH NAME CHANGE MUST BE LISTED.
__________ __________ 14. Have you ever engaged in business under a
fictitious firm name either as an individual or in the partnership or
corporate form? [ ] Yes [ ] No
If the answer is "yes" set forth particulars:
__________ __________ __________ __________ __________
VERIFICATION
I, the undersigned, state that I am the person named in the foregoing
Individual Information Sheet, that I have read and signed said Individual
Information Sheet and know the contents thereof, including all exhibits
attached thereto; and that the statements made therein, including any
exhibits attached thereto, are true. I certify/declare under penalty of
perjury that the foregoing is true and correct. Executed at __________
City County State this _____________ day of _________ . __________
(Signature of Declarant) NOTE: If this form is signed outside California
complete the verification before a notary public in the space provided
below.
State of __________ County of __________ Dated __________ at __________
__________ (Signature of Affiant)
Subscribed and sworn to before me, __________
Notary Public in and for said County and State
Note: Authority cited: Section 1344, Health and Safety Code. Reference:
Section 1351, Health and Safety Code.
HISTORY
1. Amendment filed 6-29-84; effective thirtieth day thereafter (Register
84,
No. 26).
2. Amendment filed 12-17-85; effective thirtieth day thereafter (Register
85,
No. 51).
3. Change without regulatory effect amending section filed 4-4-2000
pursuant
to section 100, title 1, California Code of Regulations (Register 2000,
No. 14).
4. Change without regulatory effect amending section filed 7-18-2000
pursuant
to section 100, title 1, California Code of Regulations (Register 2000,
No. 29).
5. Change without regulatory effect amending section filed 11-21-2002
pursuant
to section 100, title 1, California Code of Regulations (Register 2002,
No. 47).
28 CA ADC s 1300.51.1
END OF DOCUMENT
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