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 › Section 1300.89 - Petition for Restoration

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The fee for the filing of a petition for
				  restoration shall be $100 for a solicitor, $250 for a solicitor firm, and $500
				  for a plan.
(b) A petition for
				  restoration shall be made upon the following form:
(Official Use Only)
DEPARTMENT OF MANAGED CARE
File No.
							 ___________________________
(Insert file number
							 of previous filings before the
Fee Paid $___________________________
Department, if any.)
FILING FEE:
Solicitor:
							 $100
Receipt No.___________________________
Solicitor firm: $250
Plan: $500
Not refundable except
							 pursuant to
Section
							 250.15, Title 10, California
Code of
							 Regulations.
EXECUTION PAGE
DEPARTMENT OF MANAGED HEALTH CARE STATE OF
					 CALIFORNIA
PETITION FOR RESTORATION UNDER THE KNOX-KEENE HEALTH
					 CARE SERVICE PLAN ACT OF 1975
INDICATE TYPE OF FILING BY CHECKING ONE OF THE
					 FOLLOWING:
[] ORIGINAL PETITION FOR SOLICITOR
[] ORIGINAL PETITION FOR SOLICITOR FIRM
[] ORIGINAL PETITION FOR PLAN
[] AMENDMENT TO PETITION FOR SOLICITOR
[] AMENDMENT TO PETITION FOR SOLICITOR FIRM
[] AMENDMENT TO PETITION FOR PLAN
[] SUBSEQUENT PETITION
Date first petitioned for restoration
					 ____________________
Date of any subsequent petitions
					 _________________________
___________________________
1. Name of petitioner (Complete name as
				  appearing on articles of incorporation, partnership agreement, etc.)
___________________________
2. Address of principle office of petitioner.
(Number and
							 Street)
(City)
(State)
(Zip Code)
____________________________________
3.
				  Address of principle office of petitioner in the State of California.
(Number and
							 Street)
(City)
(State)
(Zip Code)
____________________________________
4.
				  Name and address of person to whom communications should be addressed
				  concerning this petition.
___________________________
5. Within 20 days of a request from the
				  Director, the petitioner shall furnish additional information as the Director
				  may require pursuant to subsection (c) of this section.
___________________________
EXECUTION
The undersigned, duly authorized by the petitioner, has
					 signed this petition on the petitioner's behalf.
___________________________
___________________________By:
(Petitioner)
___________________________Title:
I certify under penalty of perjury that I have read this
					 petition and the exhibits and attachments and know the contents, and that the
					 statements are true.
Executed at ______________________________(City)
					 ______________________________(State) on ____________________ , _____
___________________________
(Signature of Declarant)
(If executed other than in a state which permits
					 verifications under penalty of perjury, attach a verification executed and
					 sworn to before a Notary Public.)
___________________________
6. Name and address of officer or partner of
				  petitioner who is to receive compliance and informational communications from
				  the Department and who is responsible for disseminating the same within the
				  petitioner's organization.
7. Set
				  forth the grounds upon which the license, employment, or activity was
				  suspended, revoked, or barred. Attach a copy of the decision, administrative
				  record, and order suspending, revoking or barring petitioner.
8. Set forth the basis upon which petitioner
				  believes that restoration is warranted.
9. Set forth the steps which petitioner has
				  taken to prevent a recurrence of the grounds referred to in item 7, above, and
				  any other information which petitioner believes to be relevant.
10. If the petitioner is a plan, is its
				  application on file with the Department current without the need for any
				  amendment?
[] Yes [] No
If "no," state the day on which petitioner will comply with
					 subsection (c) of this section.
11. If the petitioner is a plan, attach as
				  exhibits all current reports, information, and statements which are required to
				  be filed under the Act or rules but which have not been filed to
				  date.
12. If the petitioner is a
				  solicitor firm, describe the organization of petitioner, identify its principle
				  persons, and describe the manner in which it proposes to act as a solicitor
				  firm.
13. If the petitioner is a
				  solicitor firm, attach financial statements as required:
A. If petitioner is subject to the tangible
				  net worth requirement of Section
				  1300.76.2, Title 28, Calif. Code
				  of Regulations, attach a copy of petitioner's financial statement consisting of
				  at least a balance sheet and statement reporting the results of operations for
				  the petitioner, prepared as of a date within 30 days of the filing of this
				  petition. Such financial statement need not be certified, but if not certified,
				  also attach as an exhibit certified financial statements of the petitioner as
				  of the close of its last fiscal year.
B. If petitioner is exempted from Section
				  1300.76.2, attach a statement to
				  that effect and attach a copy of petitioner's financial statement, which need
				  not be certified, consisting of at least a balance sheet and statement
				  reporting the results of operations for the petitioner, prepared as of a date
				  within 30 days of the filing of this petition.
C. If petitioner accepts no funds, in the
				  form of checks or otherwise, of plans, subscribers or other persons contracting
				  with plans (exclusive of petitioner's compensation for its solicitation
				  activities), attach a statement to that effect, and do not include financial
				  statements of the petitioner as an exhibit to the petition.
14. If petitioner has applied for restoration
				  previously and been denied, attach copies of all prior petitions,
				  administrative records, and decisions on those petitions.
___________________________