(1) General information regarding the submitter:

(2) List of primary languages used by submitter when providing services to the public as well as any threshold languages, as determined by the Department of Health Care Services, used when providing services to Medi-Cal beneficiaries;

(3) Identification of all parties to the transaction and indication whether any health care entities who are parties to the transaction will be submitting a notice. For each entity that is a party to the transaction, the submitter shall exercise reasonable diligence to ascertain and shall describe the following:

(4) Proposed or anticipated date of transaction closure;

(5) Description of transaction, which shall include the following:

(6) The submission date and nature of any applications, forms, notices, or other materials submitted or required regarding the proposed transaction to any other state or federal agency, such as, but not limited to, the Federal Trade Commission or the United States Department of Justice.

(7) Whether the proposed transaction has been the subject of any court proceeding and, if so, the:

(8) A description of current services provided by the health care entity and expected post-transaction impacts on health care services, which shall include, if applicable:

(9) If this transaction is a merger or acquisition, description of any other prior mergers or acquisitions that satisfy all of the following:

(10) Description of potential post-transaction changes to:

(11) Description of the nature, scope, and dates of any material change transactions between the submitter and any other entity that are either pending or planned to occur within 12 months following the date of the notice.

(1) If the submitter has filed notice of the transaction with the Federal Trade Commission pursuant to the Hart-Scott-Rodino Antitrust Improvements Act of 1976 and 16 C.F.R. Parts 801-803, a copy of the Premerger Notification and Report Form and any attachments thereto;

(2) Copies of all current agreement(s) and term sheets (with accompanying appendices and exhibits) governing or related to the proposed material change (e.g., definitive agreements, affiliation agreements, stock purchase agreements);

(3) Documentation sufficient to show the valuation of transaction;

(4) Contact information for any individuals signing or responsible for the transaction or side or related agreements, including names, addresses, telephone numbers, and e-mail addresses;

(5) Any pro forma post-transaction balance sheet for any surviving or successor entity;

(6) A current organizational chart of the organization of any entity party to the transaction, including charts of any parent and subsidiary organization(s), and proposed organizational chart(s) for the same entities after the transaction;

(7) Existing documentation identifying the number of patients per county or enrollees per county in the last year of any provider, payer, or fully integrated delivery system, as applicable, that is a subject of the transaction;

(8) Certified financial statements for the prior three years and any documentation related to the liabilities, debts, assets, balance sheets, statements of income and expenses, any accompanying footnotes, and revenue of all entities that are parties to the transaction. “Certified financial statements” mean audited financial reports, or if a health care entity does not routinely prepare audited financial reports, comprehensive financial statements. Comprehensive financial statements shall include details regarding annual costs, annual receipts, realized capital gains and losses, and accumulated surplus and accumulated reserves using the standard accounting method routinely used by the health care entity. Comprehensive financial statements must be supported by sworn written declarations by the chief financial officer, chief executive officer or other officer who has financial management and oversight responsibility, certifying the comprehensive financial statement is complete, true, and correct in all material matters to the best of their knowledge, and that the health care entity does not routinely prepare audited financial reports, or the most recent audited financial report is not available. For California-derived revenue requirements (as used in this Article), the certification under this paragraph requires that revenue be calculated as it was generated or occurred in California rather than when booked, accrued, or taxed;

(9) Articles of organization or incorporation, bylaws, partnership agreements, or other corporate governance documents of all entities that are parties to the transaction, including any proposed updates that occur as a result of the transaction;

(10) Any documentation related to the mitigation of any potential adverse impacts of the transaction on the public; and

(11) Any analysis and/or documents supporting the submitter's responses to the narrative answers provided pursuant to subsection (b).

(1) A submitter of a notice pursuant to this section or a submitter requesting expedited review pursuant to section 97439 may request confidential treatment of information or documents submitted. The submitter shall file two versions of any document for which confidentiality is requested. The nonpublic version shall be unredacted and shall be maintained as confidential by the Office and Department pending a determination of confidentiality. The public version, which may be made available to the public by the Office, shall have the confidential portions removed or redacted. Requests for confidentiality of publicly available information or documents will be denied.

(2) Marked-confidential versions of stock purchase agreements, compensation documents, contract rates, transaction valuation documentation provided in response to subsection (c)(3), and unredacted résumés are deemed confidential and nonpublic by the Office, pursuant to section 127507.2(c)(2) of the Code.

(3) A submitter claiming confidentiality in respect to portions of a notice, a request for expedited review, or any documents not specified in subsection (d)(2) thereafter submitted in support of the notice, shall include a justification that provides a detailed statement of the grounds enumerated in (A) through (D), below, on which confidentiality is claimed, a statement of the specific time for which confidential treatment of the information is necessary, and a statement that the information has been confidentially maintained by the entity. The detailed statement in support of the request for confidentiality shall indicate whether any of the following applies:

(4) When the Office makes a determination regarding a request for confidential treatment, the submitter will be notified in writing. If a request for confidential treatment is granted, the information will be marked “Confidential” and kept separate from the public file. With the exception of disclosure to the Attorney General pursuant to sections 127507.2(c)(1) and 127507.2(d)(1) of the Code, the Office and the Department shall keep confidential all nonpublic information and documents designated as confidential pursuant to this section. If a request for confidentiality is denied, a submitter may withdraw any information or documents for which it requested confidentiality in its submission by submitting a request through the portal.