HomeMy WebLinkAboutMINUTES - 12052000 - C142 TO, - BOARD OF SUPERVISORS �+ I
S CONTRA COSTA
COUNTY
FROM: William Walker, MD
Health Services Director
DATE:
SUBJECT: Approval and Signature of the Board for the Application to the State Department of Consumer Affairs for
Registration of the Contra Costa Health Plan Advice Nurse Service
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
commendation:
Approve the application to State Department of Consumer Affairs for Registration of the Contra
Costa Health Plan Advice Nurse Service.
Background-,
Businesses providing telephone medical advice services to California patients are required by
Section 4999 of the Business and Professions Code to register with the Department of Consumer
Affairs Telephone Medical Advice Services Program. The application must be signed by the Chair
of the Board of Supervisors and submitted prior to January 1, 2001.
Fiscalmpact:
None.
ATTACHME TMENT: xx SIGNATURE
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
�—,-'APPROVE OTHER
r
SIGNATURE(S): Q�
ACTION OF BOARD ON�Lcember 5, 2QQO APPROVED AS RECOMMENDED
VOTE OF SUPERVISORS
I HEREBY CERTIFY THAT THIS IS A TRUE
UNANIMOUS (ABSENT None �` } AND CORRECT COPY OF AN ACTION TAKEN
AND ENTERED ON THE MINUTES OF THE BOARD
AYES: _ NOES: OF SUPERVISORS ON THE DATE SHOWN,
ABSENT: ABSTAIN:
*(District V seat vaunt)
contact Person: Sussane Penf6ld 313-6008
ATTESTED
CC: Milt Camhl,CEO,CCHP PHIL BATCHELOR,CLERK OF THE BOARD OF
Auditor Controller SUPERVISORS AND COUNTY ADMINISTRATOR
County Administrator
Health Services Director
Richard Harrison,CCHP,original BY: DEPUTY
7�
1l'..TE OF CALIFORNIA-STATE AND CONSUMER SERVICES AGENCY GRAY DAVIS,Governor
TELEPHONE MEDICAL ADVICE SERVICES PROGRAM
P.O.Box 980490
Consumer West Sacramento,CA 98957-0490 a
Affairs (916)322-7898
For DWarmsent Use Onty
APPLICATION FOR REGISTRATION Receipt Number
Fee$7,500 Date Recelpted
Registration Number
INSTRUCTIONS:
1. Read the enclosed instructions and all information.
Date leaned
2. Remit fees by check or money order made payable to the Department of
Consumer Affairs.
3. Submit completed application and fees to the Telephone Medical Advice Services Program at the above address.
4. All information is mandatory and required under California Business and Professions Code and California Code of Regulations.
Please or ptint Isobly in ink
1. Name of Business: Contra Costa County dba Area Code&Phone Dumber: Area Code&Fax Number:
Contra Costa health Plan 925-313-6000 925-313-6002
2. Address of Record:
595 Center Avenue, Suite 100, Martinez, CA 94553
3. Mailing Address(If different than Address of Record):
4. Corporate Name(If different):
S. Corporate headquarters Address(If different):
6. Name of Agent for Service of Process and Address(Must be located in California):
Indicate if applicant intendsito conduct business as a soli proprietor,partnership,orlcorporation.
7. ❑ Sole Proprietor: I I 1
Name: Have you ever been convicted of a felony or misdemeanor,other than Yes
minor traffic violations?If answer is"yes,"complete Item 12.
Application will not be processed If this section is not answered. No ❑
Social Security Number: TZea-C—ode&Telephone Number:
Address: City state Zip Code
$. ❑ Partnership(Includes Limited Liability Partners):List all pakners-attach additional sheets If neceslary.
Name: Have you ever been convicted of a felony or misdemeanor,other than Yes.
minor traffic violations?If answer is"yes,"complete Item 12.
Application will not be processed If this section is not answered. No ❑
Federal Employer Identification Number: Area Code&Telephone Number:
Address: City state Tip Code
Name: have you ever been convicted of a felony or misdemeanor,other than Yes
minor traffic violations:If answer is"yes,"complete Item 11
Application will not be processed if this section is not answered. No ❑
Federal Employer Identification Number: Area Code&Telephone Number:
Address: City State Zip Code
kryrsv.dca,ca,s?or
Form A-1 2 Rev:915/00
?.;.. lE" iJlfl:List the President and Secretary of the corporation.
Publice Agency — Contra Costa County
Name&Title: have you ever been convicted of a felony or misdemeanor,other than Yes [
Ronna Gerber minor traffic violations?If answer is"yes,"complete Item UL No IC., f
Chair, Board of Su ervisors Application will not be processed if this section is not answered.
Federal Employer Identification Number: Area Code&Telephone Number:
94-6000509
Address: City State zip Code
651 fine Street Martinez CA 94.553
Name&Title: have you ever been convicted of a felony or misdemeanor,other than Yes
minor traffic violations?If answer is"yes,"complete Item 12. No
Application will not be processed if this section is not answered. rl
Federal Employer Identification Number Area Code&Telephone Number:
Address: City State Zip Code
Name&Title: Have you ever been convicted of a felony or misdemeanor,other than Yea
minor traffic violations?If answer Is"yes,"complete Item 12.
Application will not be processed If this section is not answered. No
Federal Employer Identification Number Area Code&Telephone Number:
Address: City State Zip Code
lo. 0 Limited Liability Company:List all owners of the limited liability company.
Name&'Title: Have you ever been convicted of a felony or misdemeanor,other than Yes �
minor traffic violations?If answer is"yes,"complete Item 12.
Application will not be processed if this section is not answered. No
Federal Employer Identification Number: Area Code&Telephone Number:
Address: City State Zip Code
Name&Title: have you ever been convicted of a felony or misdemeanor,other than Yes [
minor traffic violations?If answer is"yes,"complete Item 12,
Application will not be processed if this section is not answered. No d
Federal Employer Identification Number: Area Code&Telephone Number:
Address: City State Zip Code
Name&Title: Have you ever been convicted of a felony or misdemeanor,other than Yes
minor trail a violations?If answer is"yes,"complete Item 12.
Application will not be processed if this section is not answered. No
Federal Employer Identification Number: 7Area Code&Telephone Number:
Address: _ City State Zip Code
11. Have any applicants in items 7,$,9,or 10(owners,partners,officers,etc,)had any state license,certificate or registration Yes
revolved,suspended or denied or otherwise been the subject of disciplinary action by any government agency?If answer is
"yes,"complete Item 12.Application will be returned if not answered. No
12. If answer is"yes"on questions 7,8,9,10,or 11,give the particulars of each violation including code numbers and criminal case numbers if known.
(Attach additional page if necessary.)
ic^w ii.dco.ccs.trov
Form A-1 3 Rev:915/00
1:4., To satisfy the requirements of Sections 4999.1 and 4999.2 of the Business and Professions Code,you must complete Form A-2,
Provider List and attach to this application.
14. Certification:
An individual application must be signed by the owner of the business.
A partnership application(includes limited liability partnerships)must be signed by,A partners.
A Limited Liability Company application must be signed by AU owners.
A corporation application(includes limited liability companies)must be signed by either the President or Secretary.
I cert6 under penalty oaf peer u y under the kurus of the State of California that all statements made in this
application and any supporting documents pertaining to this application are true and correct I understand that
upon registration,I will he subject to all applicable taws and regulations of f`the Telephone Medical Advice Services
Program.
Sina
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signature
Print Mame
signature Tide
Print Name
Bate Signed
Disclosure of your Social Security Number(SW)is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455(42 USC'A
403(c)(2)(Q)authorize the collection of your SSN. Your SSN will be used exclusively for tax enforcement purposes,for purposes for compliance
with any judgement or order far family support in accordance with Family Code Section 17320, or for verification of licensure or examination
status by a licensing or examination entity which utilizes a national examination where licensure is reciprocal with the requesting state, if you fail
to list your SSN,your application for initial or renewal registration will not be processed. You will also be reported to the Franchise Tax Board
which may assess a$100 penalty against you.
M�rr�v ctca cur srni'
Form A-1 4 Rev:9/5/00