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 › Section 1300.51.1 - Individual Information Sheet

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
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.)
File No. ____________________
1. Name of Applicant:
___________________________
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
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).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1351,
						Health and Safety Code.