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Arizona disclosure ownership form

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DISCLOSURE OF OWNERSHIP/CONTROL AND CRIMINAL OFFENSES STATEMENTS Item I. Identifying Information a Name of Individual Facility or Organization b DBA Name c Federal Tax Identification Number TIN or Social Security Number SSN d Check the entity type that best describes the structure of the enrolling provider entity. Check only one box. For-Profit Corporation e Is this entity chain affiliated No Partnership Government Owned Sole Proprietorship Yes As required by 42 CFR Part 455 Subpart B which imp ...

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