Medicaid Bond

To keep in compliance with state and federal law, most health care professionals will be required to lodge a bond agreement before being licensed to use systems such as Medicare and Medicaid.

A bond is a legal contract that outlines all state laws and local regulations that you need to follow in order to keep your business running legitimately. The bond may even have some added clauses that you will need to adhere to in order to prevent consumers or agencies from making a claim against your bond.

The Medicare and Medicaid bond policy that you purchase is in no way to protect your business, but instead exists to protect the consumer and the system, should you be found to be guilty of any kind of fraud, whether it is claiming Medicare or Medicaid funding or defrauding a patient.

The provider of your bond, called the surety, will step in when any claims like this are made. They will investigate the claim for validity and provide you advice about your next move. Your surety is able to pay out any settlements required in the immediate, but will claim reimbursement from your business for any costs that it covers.

Before you choose a bond policy you should research some of the claims that have been validated and legal action taken so that you have a good understanding of what your bond can and cannot do for you. As an example, fraud is a crime, so while your bond may cover financial aspects of your illegal acts, the bond cannot keep you out of legal responsibility

 


Application for


Current or expiring quote we are looking to beat:


Name of previous surety company writing to the bond:


Section I: Bond Applied for

Type of Bond

Effective Date

Expiration Date


Type of Company

CORP

LLC

DBA

Partnership

Bond Amount


(Obligee)


Obligee Address


Section II: General Information

Applicant's Name

Spouse Name


SS#

Spouse SS#

Home Phone


Residence Address

City

State

Zip


Status of Residency

Own

Rent

At Current Address Since


Date of Birth

Spouse Date of Birth

Business License Number


Business Name


Business Phone

Business Fax

Business Email


Business Address

City

State

Zip


Date Business BEGAN Under Present Individual or Firm Name

Business Tax ID


Has any company refused to issue bonds for any purpose?

Yes

No

Do you have any liens, claims or judgements against you?

Yes

No


Has applicant ever failed in business?

Yes

No

Has applicant filed bankruptcy in the last 10 years?

Yes

No


If yes, Chapter 7?

Yes

No

Chapter 11?

Yes

No

Chapter 13?

Yes

No


Date Filed for Bankruptcy?


Date of Discharge?


If yes to any, please explain:


Section III: Additional Parties

Name

Spouse Name


SS#

Spouse SS#

Home Phone


Home Address

City

State

Zip


Personal Financials

(if more than one owner, each has to fill out this app)

Statement of assets and liabilities as of


Assets Liabilities
Cash in Bank Notes Payable to Banks
Cash on Hand Notes to Others(excl. of equipment)
Stocks and Bonds Accounts Payable
Accounts Receivable Federal and State Income Tax Due
Notes Receivable All Other Taxes
Inventory Accruals, Payrolls, Etc.
Cash Value Life Insurance    
Equipment Due on Equipment
Real Estate Due on Real Estate
Other Assets Other Liabilities
    Surplus and Undivided Profits
    Capital Stock(if a corporation)
       
Total Assets Total Liabilities

Net Worth


Name of Owners

Name and Title of Officers

% of Ownership


Are you an insurance agent?

Yes

No

Agent License #

Agent State

Completion of this form constitutes permission for Cal Society Insurance Services to obtain customer information which will be used to determine bonding eligibility. This information will be held in the strictest confidence.