Form HS402 "Surety Bond Verification" - California

What Is Form HS402?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2017;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HS402 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form HS402 "Surety Bond Verification" - California

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California Department of Public Health
State of California—Health and Human Services Agency
Licensing and Certification Program
SURETY BOND VERIFICATION
Reply to: California Department of Public Health
CLEAR
PRINT
Licensing and Certification Program
Centralized Applications Unit
P.O. Box 997377, MS 3207
Sacramento, CA 95899-7377
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 (9/17)
California Department of Public Health
State of California—Health and Human Services Agency
Licensing and Certification Program
SURETY BOND VERIFICATION
Reply to: California Department of Public Health
CLEAR
PRINT
Licensing and Certification Program
Centralized Applications Unit
P.O. Box 997377, MS 3207
Sacramento, CA 95899-7377
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 (9/17)