2005 Arizona Revised Statutes - Revised Statutes §20-1053  Application for certificate of authority

A. An application for a certificate of authority to operate as a health care services organization shall be filed with the director in a form prescribed by the director, shall be verified by an officer or authorized representative of the applicant and shall set forth, or be accompanied by, the following:

1. A copy of the articles of incorporation and all amendments to the articles.

2. A copy of the bylaws, rules and regulations, or similar document, if any, regulating the conduct of the internal affairs of the applicant.

3. A list of the names, addresses and official positions of the persons who are to be responsible for the conduct of the affairs of the applicant, including all members of the board of directors, board of trustees, executive committee, or other governing board or committee, the principal officers in the case of a corporation, and the partners or members in the case of a partnership or association.

4. A copy of any contract made or to be made between any providers or persons listed in paragraph 3 and the applicant.

5. A statement generally describing the health care services organization and its health care plan or plans, facilities and personnel, as approved by the director.

6. A copy of the form of evidence of coverage to be issued to the enrollees.

7. A copy of the form of the group contract, if any, that is to be issued to employers, unions, trustees or other organizations.

8. Financial statements showing the applicant's assets, liabilities and sources of financial support. If the applicant's financial affairs are audited by independent certified public accountants, a copy of the applicant's most recent regular certified financial statement shall be deemed to satisfy this requirement unless the director determines that additional or more recent financial information is required for the proper administration of this article.

9. A description of the proposed method of marketing the plan, a financial plan that includes a three-year projection of the initial operating results anticipated, and a statement as to the sources of working capital as well as any other sources of funding.

10. A power of attorney duly executed by the applicant, if not domiciled in this state, appointing the director and the director's successors in office, and duly authorized deputies, as the true and lawful attorney of the applicant in and for this state, upon whom all lawful process in any legal action or proceeding against the health care services organization on a cause of action arising in this state may be served.

11. A statement reasonably describing the geographic area or areas to be served, as approved by the director.

12. The fee prescribed by section 20-167.

13. A plan for the risk of insolvency as prescribed in section 20-1069.

14. Such other information as the director may require.

B. Within ten days following any significant modification of information previously furnished pursuant to subsection A of this section, a health care services organization shall file a notice of the modification with the director.

C. Unless preempted under federal law or unless federal law imposes greater requirements than this section, this section applies to a provider sponsored health care services organization.