Application for certificate of authority to operate prepaid health clinic.

(1) No person may operate a prepaid health clinic without first obtaining a certificate of authority from the office. The office shall not issue a certificate of authority to any applicant which does not possess a valid Health Care Provider Certificate issued by the Agency for Health Care Administration.

(2) Each application for a certificate of authority shall be on such form as the commission prescribes, and such application shall be accompanied by:

(a) A copy of the basic organizational document of the applicant, if any, such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable document, and all amendments to such document.

(b) A copy of the constitution, bylaws, rules and regulations, or similar form of document, if any, regulating the conduct of the affairs of the applicant.

(c) A list of the names, addresses, and official capacities with the applicant of the persons who are to be responsible for the conduct of the affairs of the clinic, including all members of the governing body, the officers and directors in the case of a corporation, and the partners or associates in the case of a partnership or association. Such persons shall fully disclose to the office and the governing body of the clinic the extent and nature of any contracts or arrangements between them and the clinic, including any possible conflicts of interest.

(d) A statement generally describing the clinic and its operations.

(e) Each form of prepaid health clinic contract that the applicant proposes to offer the subscribers, showing for each form of contract the benefits to which the subscribers are entitled, together with a table of the rates charged, or proposed to be charged.

(f) A copy of the applicant’s Health Care Provider Certificate from the Agency for Health Care Administration, issued pursuant to part III of this chapter.

(g) A financial statement prepared on the basis of generally accepted accounting principles, except that surplus notes acceptable to the office may be included in the calculation of surplus.