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Kansas seller disclosure form

Kansas disclosure 2026

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The document outlines the requirements for the Disclosure of Ownership and Control Interest Statement for providers participating in the Kansas Medical Assistance Program (KMAP). It mandates the collection of detailed ownership, control interest, and management information from Medicaid and CHIP providers, including identities of owners with significant interests, managing employees, business transactions, and criminal conviction history. Submission of this disclosure is essential for participation in KMAP, with consequences for non-compliance.

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Click ‘Get Form’ to open the Kansas Disclosure of Ownership and Control Interest Statement in the editor.
Begin by filling out the provider entity's name, date of birth, EIN/SSN, and NPI. Ensure all fields are complete to avoid processing delays.
In Question 1, list all individuals or corporations with a direct or indirect ownership interest of 5% or more. Include their primary address and percentage of ownership.
For Question 2, indicate if any listed individuals are related. Specify their relationships clearly.
Continue with Questions 3 through 15, providing detailed information about business transactions, managing employees, criminal convictions, and other required disclosures as specified.
If additional space is needed for any question, note it on the form and attach a separate sheet referencing the question number.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (25 Votes)
2014	4.3 Satisfied (87 Votes)

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