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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 ture Tide ame /aw-L-�Z4�..J 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