28 CA ADC § 1300.99
28 CCR s 1300.99
Cal. Admin. Code tit. 28, s 1300.99
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 14. MISCELLANEOUS PROVISIONS
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.99. Application to Surrender License.
An application to surrender a license as a health plan shall be filed with
the Director, in the following form:
DEPARTMENT OF MANAGED HEALTH CARE STATE OF CALIFORNIA APPLICATION FOR
SURRENDER
OF LICENSE PURSUANT TO SECTION 1399, HEALTH AND SAFETY CODE
Date of Application Dept. of Managed Care
_____________ File No._____________
_______________
1. Name of Licensee (as appearing in license)
________________________________________________________________
2. Person to be contacted regarding this application.
Name________________________________________________
Address_________________________________________________________
________________________________________________________________
Telephone Number________________________________________________
3. Reason for Surrender of License (explain briefly):
4. Date upon which licensee proposes to terminate business:
________________________________________________________________
If the date is subject to contingencies or will be determined hereafter,
explain briefly below:
5. Complete the following:
a. Attach a copy of the balance sheet and a statement of income and
expense for the plan, prepared as of a date within 30 days of the filing
of this application. Such financial statements need not be certified.
b. State whether the licensee is required to file certain reports pursuant
to Section 1384 of the Knox-Keene Health Care Service Plan Act of 1975.
If so, state the date by which the licensee will forward such reports to
the Director:
c. Section 1300.85.1. of the rules pursuant to the Knox-Keene Health Care
Service Plan Act of 1975 requires that the books and records of a plan be
preserved for a period of five years.
State the name and address of the custodian of the plan's books and
records and the address at which such records will be located:
Custodian:___________________________________________________
_________________________________________________________
Location:____________________________________________________
_________________________________________________________
d. Describe in an attachment hereto the licensee's plans for the
termination of its business as a health care service plan or specialized
health care service plan, including the following information:
1. The provision for payment of any amounts due to subscribers and
enrollees and the aggregate amount owed thereto.
2. The provision for payment of any amounts due to providers of health
care services, the aggregate owed thereto and a schedule showing the
persons to whom such amounts are owed, the amount due each such person,
and the date such liability first became due and payable.
3. The final date for payment of periodic payments by or on behalf of
subscribers for health care services, and the final date which the plan
will be obligated to furnish health care services by reason of such
payments.
4. If an insurer assumes obligations as to the plans subscribers and
enrollees, attach a detailed statement of the plan for the assumption of
business by the subsequent provider or insurer, including the provision
being made for notice to subscribers and enrollees, group representatives
and providers of health care services who contract with the plan.
5. If the plan or any provider of health care services to the plan holds
medical records as to any subscriber or enrollee, indicate the disposition
to be made of such records, including the provision made for its
subsequent availability to persons providing health care services to such
subscribers and enrollees.
e. Is the plan's application pursuant to Section 1351 of the Knox-Keene
Health Care Service Plan Act of 1975 current, reflecting all matters which
require an amendment to such application pursuant to Rules 1300.52,
1300.52.1 or 1300.52.2?
Yes No
If "no" attach an amendment(s) to such application in conformance with
such rules
f. Is the plan currently involved in any civil or administrative
proceeding?
Yes No
If "yes" furnish full details, including the court or administrative
action before which such matter is pending.
6. The licensee has duly caused this application to be signed on its
behalf by the undersigned, thereunto duly authorized.
__________________________
(Licensee)
By__________________________
Title__________________________
I certify under penalty of perjury that I have read this application and
the attachments hereto and know the contents thereof, and that the
statements therein are true.
Executed at_____________________________________on___________
______________________________________
Signature of Declarant
If executed in a jurisdiction which does not permit verification under
penalty of perjury, attach a verification executed and sworn to before a
notary public.
Note: Authority cited: Section 1344, Health and Safety Code. Reference:
Section 1399, Health and Safety Code.
HISTORY
1. Amendment filed 1-12-83; effective thirtieth day thereafter (Register
83,
No. 3).
2. Amendment filed 7-3-84; effective thirtieth day thereafter (Register
84,
No. 27).
3. Change without regulatory effect amending subsection (e) 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 1300.99
END OF DOCUMENT
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