California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 4 - Certification Standards for Health Care Organizations › Section 9771.63 - Individual Information Sheet (WCHCPO 2)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
An individual information sheet required pursuant to
						these rules shall be in the following form:
CONFIDENTIAL
DIVISION OF WORKERS' COMPENSATION
State of California
INDIVIDUAL INFORMATION SHEET
under Labor Code Section
						4600.6
1. Name of Applicant:
File
								No.____________________
___________________________
2. Exact full name of person completing this
					 statement:
___________________________
First
Middle
Last
3. Have you ever had a certificate, license,
					 permit registration or exemption issued pursuant to the Business and
					 Professions Code, Health and Safety Code, Insurance Code, or Labor 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.
___________________________
___________________________
___________________________
4. 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:
___________________________
___________________________
___________________________
5. 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.
___________________________
___________________________
___________________________
6. 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 and correct.
I certify (or declare) under penalty of perjury under the
						laws of the State of California that I have read this Individual Information
						Sheet and the exhibits thereto and know the contents thereto, and that the
						statements therein are true and correct.
Executed at ______________________________(Place) on
						______________________________(Date)
__________________________________________________
(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
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.