Cal. Code Regs. tit. 28 § 1300.51.1

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Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 1300.51.1 - Individual Information Sheet

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

Cal. Code Regs. Tit. 28, § 1300.51.1

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.