Interest form scdhhs 2026

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The document provides instructions for applicants seeking Medicaid provider enrollment, detailing the required disclosures for ownership and control interests. It outlines the necessary information to be submitted by individual practitioners and entities, including personal details, criminal history, ownership interests, and relationships among individuals involved. The document emphasizes compliance with federal regulations and the consequences of providing false information. It also includes sections for managing employees, subcontractors, and any changes in provider status.

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Click ‘Get Form’ to open the interest form scdhhs in the editor.
Begin with Part 1. Indicate if you are enrolling as an individual practitioner by selecting 'Yes' or 'No'. If 'Yes', complete all fields in Part 1.
Fill in your personal information, including your full name, SSN, date of birth, and NPI if applicable. Ensure all fields marked with an asterisk (*) are completed.
Answer the question regarding any criminal convictions related to Medicaid. If applicable, provide details about the charges and their disposition.
Proceed to sign and date the certification statement at the end of Part 1, confirming that all information is accurate.
If you are required to complete Part 2, follow similar steps for providing ownership and control interest information as outlined in the document.

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