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Enter name of individual or entity depending on who the Disclosure is in regards to - chfs ky

Enter name of individual or entity depending on who the Disclosure is in regards to - chfs ky 2026

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The document is a 'Disclosure of Ownership' form required by federal and state law for Kentucky Medicaid providers. It outlines the necessary information to be disclosed regarding ownership, management, and control interests in the disclosing entity. Key sections include details about individuals or entities with significant ownership stakes, anticipated changes in ownership or bankruptcy, relationships among owners, and any criminal convictions related to Medicaid programs. The form must be completed accurately to avoid rejection and potential termination from the Medicaid program.

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Click ‘Get Form’ to open the Disclosure of Ownership document in the editor.
Begin by entering the name of the individual or entity that this disclosure pertains to in Field 1.
In Field 2, input the KY Medicaid provider number associated with this disclosure.
For Field 3, indicate if you anticipate any changes in ownership or management within the next year. If applicable, provide the anticipated date and nature of the change.
Field 4 requires you to state if you plan to file for bankruptcy within the year. Enter the anticipated date if applicable.
Continue filling out Fields 5 through 21, ensuring all required information is provided accurately. Attach additional sheets as necessary for detailed disclosures.

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Who is the director of the Kentucky health Department?

Steven J. Stack was appointed commissioner for public health for the Commonwealth of Kentucky in February 2020 and was elected secretary-treasurer of the Association of State and Territorial Health Officials in Fall 2020 and president-elect in 2022. Dr.

Who is the director of the Kentucky cabinet for health and family services?

Melissa Goins - Director - Commonwealth of Kentucky Cabinet for Health and Family Services | LinkedIn.

How to become a Medicaid provider in Kentucky?

To enroll in Kentucky Medicaid, please go to the Medicaid Provider Portal Application (MPPA). Providers who are not participating need to request a contract by completing the provider nomination form. Once completed please return to KYProviderUpdates@Aetna.com.

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