State of California--Health and Human Services Agency California Department of Public Health AFFIDAVIT REGARDING PATIENT MONEY In accordance with California Health and Safety Code, Section 1318, this form is intended to ensure that all licensed health facilities comply with statutory bonding requirements if they handle patient money. This form is required on all new applications and whenever the Department deems it is necessary to reevaluate the bonding need of a health facility. I (We) Name(s) of Applicants (i.e., licensee) As applicant(s) for Name of Facility Facility address Street City State ZIP Code County I (We) certify that I (check A or B below): A. Will handle less than $25 per patient and less than $500 for all patients in any one month. B. Will handle more than $25 per patient or more than $500 for all patients in any one month. (If B is checked, please indicate the maximum amount of money that will be handled.) Amount of money to be handled. ................................................................................................. Note: If "B" is checked, you will need to submit a Surety Bond Verification (form HS 402). Money Handled Bond Required Money Handled Bond Required $ $ 500.00 to 750.00 $ 1,000.00 $10,501.00 to 11,500.00 $12,000.00 751.00 to 1,500.00 2,000.00 11,501.00 to 12,500.00 13,000.00 1,501.00 to 2,500.00 3,000.00 12,501.00 to 13,500.00 14,000.00 2,501.00 to 3,500.00 4,000.00 13,501.00 to 14,500.00 15,000.00 3,501.00 to 4,500.00 5,000.00 14,501.00 to 15,500.00 16,000.00 4,501.00 to 5,500.00 6,000.00 15,501.00 to 16,500.00 17,000.00 5,501.00 to 6,500.00 7,000.00 16,501.00 to 17,500.00 18,000.00 6,501.00 to 7,500.00 8,000.00 17,501.00 to 18,500.00 19,000.00 7,501.00 to 8,500.00 9,000.00 18,501.00 to 19,500.00 20,000.00 8,501.00 to 9,500.00 10,000.00 19,501.00 to 20,500.00 21,000.00 9,501.00 to 10,500.00 11,000.00 20,501.00 to 21,500.00 22,000.00 Every additional increment of $1,000.00 or fraction thereof shall require an additional $1,000.00 on the bond. Licensees are required to: O O Immediately notify the licensing agency in writing when the stated amount is exceeded. Maintain adequate safeguards and accurate records of monies and valuables entrusted to the facility, in accordance with regulations of the State Department of Public Health. I (We) certify that the foregoing statements are true to the best of my (our) knowledge. Print name Title Signature Date RELEASE OF INFORMATION STATEMENT The information provided on this form is mandatory and is necessary for licensure approval. It will be used to determine individual applicant's or applicant facility's ability to provide health services. The information is requested by the California Department of Public Health, Licensing and Certification, in accordance with Health and Safety Code, Sections 1253, 1265, and 1267.5, and California Code of Regulations (CCR), Title 22, Sections 70107, 70137, 71107, 71135, 73205, 73241, 76205, and 76241. Failure to provide the information as requested or submission of willful false statements may result in nonissuance of a license or license revocation. The information is considered public information and will be made available to the public upon request. The information shall be included and maintained in the individual facility's public files located in Licensing and Certification district offices. HS 400 (2/08) American LegalNet, Inc. www.FormsWorkflow.com