28 CA ADC § 1300.84.6


      28 CCR s 1300.84.6

      Cal. Admin. Code tit. 28, s 1300.84.6


      CALIFORNIA CODE OF REGULATIONS
      TITLE 28. MANAGED HEALTH CARE
      DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
      CHAPTER 2. HEALTH CARE SERVICE PLANS
      ARTICLE 12. REPORTS
      This database is current through 06/09/06, Register 2006, No. 23.

      s 1300.84.6. Plan Annual Enrollee Report.

      (a) On or before May 15th of each year, each licensed plan shall file a 
      report in the following form and containing the information specified 
      therein:


      State of California         Dept. of Managed Care
      Department of Managed Care  File Number________

       

      REPORT OF ENROLLMENT IN PLAN Knox-Keene Health Care Service Plan Act


      _______________________________________________________________________________
      1. Name of Plan:
      _______________________________________________________________________________
      2. Name, mailing address, and telephone number of Plan official to whom
        communications concerning this report should be addressed:
      ______________________________________
      Name                                    Phone No. -Include area code
      _______________________________________________________________________________
       Mailing Address
      _______________________________________________________________________________
       City, State and ZIP Code
      3. For the purposes of Section 1356(b) of the Knox-Keene Health Care 
      Service
        Plan Act, the Plan reports that, as of March 31 of the year in which 
this
        report is made, its records reflected the following enrollments, in
        accordance with the definitions contained in Section 1345, Health and 
      Safety
        Code:
      Number of 
      subscribers__________________________________________________________
      Number of 
      enrollees____________________________________________________________
      (Note: As required by Section 1356(b), if the number of enrollees is 
      estimated,
        the method used for determining the estimated enrollment must be 
      disclosed.)
      4. Execution: I certify under penalty of perjury that the above statement 
      is
        true.
      Executed at___________________________   
      on____________________________________
      City and State                          Date
      _______________________________________________________________________________
                                              Signature
      _______________________________________________________________________________
                                              Print or Type Name of Declarant
      _______________________________________________________________________________
                                              Position with Plan
                                              
      _______________________________________

       

      


      Note: Authority cited: Section 1344, Health and Safety Code. Reference: 
      Sections 1356, 1384 and 1385, Health and Safety Code. 


       HISTORY 
         
      1. New section filed 5-9-80; effective thirtieth day thereafter (Register 
      80, 
      No. 19).

      2. Change without regulatory effect amending section filed 1-23-91 
      pursuant to 
      section 100, title 1, California Code of Regulations (Register 92, No.
      10).

      3. Change without regulatory effect amending subsection (a) filed 
7-18-2000
      pursuant to section 100, title 1, California Code of Regulations (Register
      2000, No. 29).
      28 CA ADC s 1300.84.6

      END OF DOCUMENT

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