Notice of Intention to Rely upon the Rural Ambulance Plan ExemptionEmployee Assistance Program Exemption Rule 1300.43.14

Form 1300.43.14 Employee Assistance Program Exemption

*1052EAP01*

1052EAP01

STATE OF CALIFORNIA

DEPARTMENT OF MANAGED HEALTH CARE

NOTICE OF INTENTION TO RELY UPON THE RURAL

AMBULANCE PLAN EXEMPTION UNDER THEEMPLOYEE ASSISTANCE PROGRAM

EXEMPTION RULE 1300.43.14

KNOX-KEENE

HEALTH CARE SERVICE PLAN ACT OF 1975

Original Notice / Amendment to Notice Dated / Date

The Plan named beloww herebyperson/entity named in item 1 below files this notice/amended notice claiming the exemption pursuant to Rule 1300.43.14 under the Knox-Keene Health Care Service Plan Act:

  1. 1. Name of Licensee (as appearing in license).Legal name of person or entity filing this notice:

  1. 2. Person to be contacted regarding this applicationAddress of principal office, and if different, mailing address:.

NameNumber and Street or PO Box (Principal Office)
AddressCity, State, and Zip Code
Number and Street or PO Box (Mailing Address)
City, State, and Zip Code
  1. Fictitious names used in connection with the operation of employee assistance programs
(If none, so specify):
  1. Identify each location at which the plan maintains records subject to inspection by the Director under Rule 1300.43.14(a)(6) (if space is insufficient, continue on separate sheet):3. Reason for Surrender of License

  1. Name, title, address and telephone number of representative who may be contacted concerning this notice:

  1. The person/entity filing this notice declares hereby that it is in compliance with the provision of Rule 1300.43.14, and undertakes to amend this notice within 30 calendar days of any material change in the information specified in its current notice as filed with the Director of the Department of Managed Health Care.

Date of Notice
(Name of Person/Entity Filing Notice)
(Signature of Authorized Officer)
(Printed Name and Title of Signatory)
Verification:
I certify under penalty of perjury under the laws of the State of California that I have read this Notice and its attachments thereto and know the contents thereof, and that the statements therein are true and correct.
Executed at Custodian: / On
(City and State) / (Date)
Location:
Signature
(If executed in a jurisdiction which does not permit verifications under penalty of perjury, attach a verification executed and sworn to before a notary public.)
Describe in an attachment thereto the licensee’s plans for the termination of its business as a health care service plan or specialized health care service plan, including the following information:
The provision for payment of any amounts due to subscribers and enrollees and the aggregate amount owed thereto.
The provision for payment of any amounts due to providers of health care services, the aggregate owed thereto and a schedule showing the persons to whom such amounts are owed, the amount due each such person, and the date such liability first became due and payable.
The final date for payment of periodic payments by or on behalf of subscribers for health care services and the final date which the plan will be obligated to furnish health care services by reason of such payments.
If an insurer assumes obligations as to the plans subscribers and enrollees, attach a detailed statement of the plan for the assumption of business by the subsequent provider or insurer, including the provision beiing made for notice to subscribers and enrollees, group representatives and providers of health care services who contract with the plan.
If the plan of any provider of health care services to the plan holds medical records as to any subscriber or enrollee, indicate the disposition to be made of such records, including the provision made for its subsequent availability to persons providing health care services to such subscribers and enrollees.
e. Is the plan’s application pursuant to Section 1351 of the Knox-Keene Health Care Service Plan Act of 1975 current, reflecting all matters which require an amendment to such application pursuant to Rules 1300.52, 1300.52.1 or 1300.52.2? Yes No
If “No” attach an amendment(s) to such appllication in conformance with such rules.
f. Is the plan currently involved in any civil or administrative proceeding? Yes No
If “Yes” furnish full details, including the court or administrative action before which such matter is pending.
6. The licensee has duly caused this application to be signed on its behalf by the undersigned, thereunto duly authorized.
(Licensee)
By:
Title:

I certify (or declare) under penalty of perjury under the laws of the State of California that I have read this application and the exhibits and attachments thereto and know the contents thereof, and that the statements therein are true and correct.

Executed at (City & State)
Executed on (Date) / By:

Signature of Declarant

Department of Managed Health Care1October 311, 2001