Where this sits
- Chapter 4.5.
- Division of Workers' Compensation
- Subchapter 1. Administrative Director--Administrative Rules
- Article 4. Certification Standards for Health Care Organizations
The regulation, as printed
An individual information sheet required pursuant to these rules shall be in the following form: CONFIDENTIAL DIVISION OF WORKERS' COMPENSATION State of California INDIVIDUAL INFORMATION SHEET under Labor Code Section 4600.6 1. Name of Applicant: File No._________ 2. Exact full name of person completing this statement: First Middle Last 3. Have you ever had a certificate, license, permit registration or exemption issued pursuant to the Business and Professions Code, Health and Safety Code, Insurance Code, or Labor 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. 4. 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: 5. 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. 6. 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 and correct. I certify (or declare) under penalty of perjury under the laws of the State of California that I have read this Individual Information Sheet and the exhibits thereto and know the contents thereto, and that the statements therein are true and correct. Executed at ____________________on (Place) (Date) _________________________________________ (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
The statute above this rule
Every regulation names the Labor Code it was written under. This is where the two halves of the law meet.
ImplementsLabor Code § 4600.3Labor Code § 4600.6
Authority and history
Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.
1. New section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only pursuant to Stats. 1997, Ch. 346, Section 5 (Register 98, No. 16).
No released decision named this rule
Not a comment on the rule — most of Title 8 never reaches a published panel decision, because most of it is followed without argument. The text above is the state's own.
Rules beside this one
Article 4. Certification Standards for Health Care Organizations — regulations rarely stand alone, and the answer is often two sections away.
- § 9771.6Application of Regulations Concerning Workers' Compensation Health Care Provider Organizations.
- § 9771.60Further Definitions.
- § 9771.61Prohibition of Bonuses or Gratuities in Solicitations.
- § 9771.62Application for Authorization as a Workers' Compensation Health Care Provider Organization.
- § 9771.64Organization Assurances Prior to Solicitation.
- § 9771.65Filing of Advertising and Disclosure Forms.