Mltc 62 form 2025

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The document outlines the Nebraska Department of Health and Human Services' requirements for ownership, controlling interest, and conviction disclosure for Medicaid providers. It mandates the completion of a form that collects identifying information about the entity and its owners, including their relationships, managing employees, and any criminal convictions related to Medicare or Medicaid involvement. The form must be submitted during enrollment or upon request, ensuring compliance with federal regulations.

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