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AmeriGroup Disclosure of Ownership and Control Interest Statement

AmeriGroup Disclosure of Ownership and Control Interest Statement 2026

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The document is a Disclosure of Ownership and Control Interest Statement for Amerigroup Community Care, detailing the ownership structure, potential criminal convictions of individuals with controlling interests, and operational changes within the organization. It includes questions regarding ownership percentages, affiliations with other Medicare/Medicaid facilities, changes in management, and bed capacity adjustments. The document emphasizes the importance of accurate disclosures to avoid legal repercussions.

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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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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is an example of a disclosing entity?

Agent means any person who has been delegated the authority to obligate or act on behalf of a provider. Disclosing entity means a Medicaid provider (other than an individual practitioner or a group of practitioners), or a fiscal agent.

What is a person with an ownership or control interest?

Person with ownership or control interest means a person or corporation that: Has an ownership interest totaling 5 percent or more in a disclosing entity; Has an indirect ownership interest equal to 5 percent or more in a disclosing entity; Has a combination of direct and indirect ownership interests equal to 5 percent

What is ownership disclosure?

It helps ensure providers have not been unfairly barred from providing services under any federal health care program. It also helps ensure that Medicaid providers do not have relationships with individuals or entities that have been excluded or terminated from participating in any federal health care program.

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