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AmeriGroup Disclosure of Ownership and Control Interest Statement 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling in the Identifying Information section. Enter the Name of Entity, Business Address, City, State, ZIP, and Phone number accurately.
- Proceed to answer the questions in Section II by selecting YES or NO. If you select YES for any question, provide details in the Remarks section on Page 2.
- In Section III, list names and addresses for individuals or EINs for organizations with ownership or control interest. Specify the Type of Entity and indicate if any owners are associated with other Medicare/Medicaid facilities.
- Continue through Sections IV to VIII, answering questions regarding changes in ownership, management affiliations, bed capacity increases, and more as applicable.
- Finally, ensure that the Name of Authorized Representative is typed or printed clearly along with their Title, Signature, and Date at the end of the form.
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