Section 1300.51.1 - Individual Information Sheet (California Code of Regulations)

§ 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.)

1. Name of Applicant: File No. ____________________ ________________________________________

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.

Disclaimer: All information on this page is frequently updated based on official sources. However, Lawrina cannot accept any responsibility for the accuracy of the content for Section 1300.51.1 Individual Information Sheet. To check for possible violations, please check the official sources.

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