Provider Subcontractor Disclosure of Ownership Controlling Interest Worksheet 2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. If applicable, indicate if the primary business address has changed and provide the new address. Include any additional business locations as necessary.
4. 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.
5. For each person listed, specify their relationship to others with ownership interests and disclose any other entities they are associated with that require disclosure.
6. Complete sections regarding managing employees and service addresses. Ensure all service locations are documented to avoid nonparticipation issues.
7. Finally, certify that all information is accurate by signing and dating the form before submission.

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