In the intricate world of health and human services, ensuring the integrity and security of patient funds stands paramount. This principle is embodied in the form known as the HS 402, utilized within the California Department of Public Health's Licensing and Certification Program. At its core, this surety bond verification form acts as a protective measure, safeguarding patient monies that exceed certain thresholds within licensed health facilities. Stemming from the mandates of the California Health and Safety Code, Section 1318, it is a legal requirement for facilities handling more than $25 per patient or over $500 for all patients in any given month to secure a bond of no less than $1,000. The bond serves as a financial assurance, committing to the honest management of patient funds. Completion of the HS 402 form, accompanied by an original bond copy, is a critical step for bonding agencies. Furthermore, it details the conditions under which the bond can be voided and the repercussions in instances of financial mismanagement. This form not only delineates the obligations of the bonded entities but also extends a recourse to patients, empowering them to take legal action for any financial grievances. With its introduction, the HS 402 form underscores a commitment to upholding the financial welfare of patients within California's health facilities.
| Question | Answer |
|---|---|
| Form Name | California Form Hs 402 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names |
State of |
California Department of Public Health |
|
Licensing and Certification Program |
SURETY BOND VERIFICATION
Reply to: California Department of Public Health
Licensing and Certification Program
Centralized Applications Unit
P.O. Box 997377, MS 3402
Sacramento, CA
California Health and Safety Code, Section 1318, Chapter 2, Division 2, requires that licensed health facilities that handle money in excess of $25 per patient or over $500 for all patients in any month, be bonded for not less than $1,000. This is to serve as a guarantee for the faithful and honest handling of the money of such patients.
INSTRUCTIONS: This form is to be completed by the bonding agency. In addition, attach an original copy of the bond. In the event of cancellation of the bond, please send notice to the above licensing office.
BE IT KNOWN THAT:
Facility name
Facility address |
|
|
|
|
|
City |
|
|
|
|
County |
|
|
ZIP code |
|
|
|||
State of California, as Principal, and |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Bonding agency |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Agency address |
|
|
|
|
|
City |
|
|
|
|
County |
|
|
ZIP code |
|
||||
State of |
|
|
, as Surety, are held and firmly bound unto the STATE OF CALIFORNIA in the full and just sum of |
||||||||||||||||
|
|
|
DOLLARS ($ |
|
|
|
), for the payment of which the said Principal and said Surety |
||||||||||||
bind themselves, their respective heirs, successors, and assigns, jointly and severally, firmly by these presents. |
|
|
|
|
|
||||||||||||||
The CONDITION of this obligation is such that |
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
WHEREAS, the Principal has applied for or has been issued a license by the California Department of Public Health to maintain or conduct a health facility pursuant to Chapter 2, Division 2, of the Health and Safety Code of the State of California; and
WHEREAS, by the terms of Section 1318 of said code, the Principal is required to file with the California Department of Public Health, Licensing and Certification, the bond running to the State of California.
NOW, THEREFORE, if the above bounden Principal shall faithfully and honestly handle money of patients in the care of said Principal, then this obligation shall be null and void; otherwise to remain in full force and effect.
Every patient injured as a result of any improper or unlawful handling of the money of a patient of a health facility may bring an action in a proper court on the bond required to be posted by the licensee pursuant to this section for the amount of damage he/she suffered as a result thereof to the extent covered by the bond.
This bond may be canceled by the Surety in accordance with the provisions of Section 996.310 et seq. of the Code of Civil |
|
|
|
|||||||
Procedure. This bond is effective |
and continuous. |
|
|
|
|
|
|
|||
|
Date |
|
|
|
|
|
|
|
|
|
IN WITNESS WHEREOF, we have subscribed our names and impressed our seal this |
|
, |
|
, |
|
. |
||||
|
|
|
|
|
Day |
Month |
|
Year |
||
|
|
|
|
|
|
|
|
|
||
Bonding agent name (please print) |
|
|
|
Bonding agent signature |
|
|
|
|
||
BONDING AGENCY SEAL
HS 402 (2/08)