Mltc 62 form 2026

1. Click ‘Get Form’ to open the MLTC 62 form in the editor.
2. Begin by filling out the Identifying Information section. Enter the legal name of your entity, provider number, and contact details including address, phone number, and email.
3. In Section A, list each person with an ownership or control interest. Include their name, SSN/FTIN, address, percentage of interest, and date of birth. If more space is needed, attach a separate list.
4. Proceed to Section B to indicate if any listed individuals are related. Check 'Yes' or 'No' and provide names and relationships if applicable.
5. For Section C, identify managing employees by providing their names, SSNs, position titles, and dates of birth.
6. In Section D, disclose any ownership interests in other Nebraska Medicaid providers as required.
7. Finally, complete Section E by listing any individuals with convictions related to Medicare or Medicaid programs. Ensure all information is accurate before signing the provider statement at the end.

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