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Ownership and Control Disclosure Form - AmeriHealth Caritas

Ownership and Control Disclosure Form - AmeriHealth Caritas 2026

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The document is an intake form for AmeriHealth Caritas North Carolina, designed to collect comprehensive facility data from healthcare providers. It includes sections for provider identification, practice locations, office hours, ADA compliance, and services offered. The form requires detailed information such as entity names, contact details, facility addresses, languages spoken, and types of services provided at each location.

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Click ‘Get Form’ to open it in the editor.
Begin with Section 1, entering the provider entity name as it appears on the W9. Fill in the applicable fields such as billing type and primary contact information.
Proceed to Section 2, where you will list all practice locations. Ensure to include facility names, addresses, and NPI or Atypical ID information for each location.
In Section 3, indicate ADA compliance for each location by checking the appropriate boxes based on accessibility features available.
Finally, complete Section 4 by selecting the services provided at each location and specifying age ranges served. Review all entries for accuracy before submission.

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Is AmeriHealth Caritas the same as Medicaid?

To provide Medicaid services, most states contract in some way with private managed care companies, or managed care organizations (MCOs), such as AmeriHealth Caritas. MCOs accept a set per-member-per-month payment from the state.

What is a disclosing entity in Medicaid?

Disclosing entity means a Medicaid Provider (other than an individual practitioner or group of practitioners), or a Fiscal Agent. For purposes of the Contract, Disclosing Entity means the Contractor.

What is disclosure of ownership for CAQH?

What is the purpose of the Disclosure of Ownership section? CAQH ProView includes a new group of questions within the Disclosure section. These questions are related to disclosing any ownership or financial interests related to the location a provider practices.

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How do I apply for AmeriHealth Caritas PA?

You can talk to an enrollment specialist by calling 1-800-440-3989 (TTY users call 1-800-618-4225). You can also enroll online. The enrollment specialist can help you with enrolling new family members or answering questions about your choices of health plans. They can also help if you decide to change health plans.

What is the meaning of disclosure form?

What is a Disclosure Form? A disclosure form is a formal document that contains all the terms, conditions, assets, risks, and liabilities associated with a specific contract or agreement.

Does AmeriHealth Caritas have a provider portal?

The Provider Engagement, Analytics Reporting (PEAR) portal offers participating providers a single point of entry to multiple digital tools, including PEAR Practice Management, PEAR Comprehensive Visit, and PEAR Analytics and Reporting.

What is an ownership disclosure form?

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.

What is a disclosure of ownership form?

The submissions of a Provider Entity Disclosure of Ownership, Controlling Interest and Management Statement (Provider Entity form) is a federal regulation requirement under 42 CFR Part 455, applicable to all providers that participate in state-based health care programs, such as Medicaid CHIP, and provide services

Ownership and Control Disclosure Form - AmeriHealth Caritas 2026

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