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Provider Subcontractor Disclosure of Ownership Controlling Interest Worksheet 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the identifying information of the provider or subcontractor. Fill in the name, type, Tax ID, NPI, and Medicaid provider ID in the designated fields.
- If applicable, indicate if the primary business address has changed and provide the new address. Include any additional business locations as necessary.
- In the 'Disclosure of Ownership & Control Interest' section, list individuals or organizations with a direct or indirect ownership interest of 5% or more. Ensure to include all required details such as addresses and tax identification numbers.
- For each person listed, specify their relationship to others with ownership interests and disclose any other entities they are associated with that require disclosure.
- Complete sections regarding managing employees and service addresses. Ensure all service locations are documented to avoid nonparticipation issues.
- Finally, certify that all information is accurate by signing and dating the form before submission.
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The disclosing entity is required to fully disclose all individuals who have an ownership interest of 5% or more. The disclosing entity is also required toRead more
This comprehensive risk contract is entered into this day of , and is effective on the. day of between the Department of Human