Section 1300.84.6 - Plan Annual Enrollee Report (California Code of Regulations)

§ 1300.84.6. Plan Annual Enrollee Report

(a) On or before May 15th of each year, each licensed plan shall file a report in the following form and containing the information specified therein:

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State of California

Dept. of Managed Care

Department of Managed Care

File Number________

REPORT OF ENROLLMENT IN PLAN Knox-Keene Health Care Service Plan Act

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1. Name of Plan:

  

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2. Name, mailing address, and telephone number of Plan official to whom communications concerning this report should be addressed:

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Name

Phone No. -Include area code

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Mailing Address

  

_

City, State and ZIP Code

  

3. For the purposes of Section 1356(b) of the Knox-Keene Health Care Service Plan Act, the Plan reports that, as of March 31 of the year in which this report is made, its records reflected the following enrollments, in accordance with the definitions contained in Section 1345, Health and Safety Code:

Number of subscribers_

Number of enrollees_

(Note: As required by Section 1356(b), if the number of enrollees is estimated, the method used for determining the estimated enrollment must be disclosed.)

4. Execution: I certify under penalty of perjury that the above statement is true.

Executed at_

on_

City and State

Date

_

  

Signature

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Print or Type Name of Declarant

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Position with Plan

  

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(1. New section filed 5-9-80; effective thirtieth day thereafter (Register 80, No. 19). 2. Change without regulatory effect amending section filed 1-23-91 pursuant to section 100, title 1, California Code of Regulations (Register 92, No. 10). 3. Change without regulatory effect amending subsection (a) filed 7-18-2000 pursuant to section 100, title 1, California Code of Regulations (Register 2000, No. 29).)

Note: Authority cited: Section 1344, Health and Safety Code. Reference: Sections 1356, 1384 and 1385, Health and Safety Code.

Disclaimer: Lawrina makes great effort to keep legal information accurate and updated. However, we cannot guarantee that Section 1300.84.6 Plan Annual Enrollee Report is an exact copy of the official text as updates may have been made. Please check the accuracy of the information provided against the official resources.

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