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Click ‘Get Form’ to open the united healthcare disclosure of ownership control interest and management statement form in the editor.
Begin by filling out the 'Contracted Provider Entity Information' section. Ensure every field is complete, including the type of disclosing entity, legal name, and complete address.
Proceed to Section I: Provider Entity Ownership Information. Indicate if there are individuals or organizations with a Direct or Indirect Ownership or Controlling Interest of 5% or more. If yes, provide their details as required.
Continue to Section II: Ownership in Other Providers & Entities. If applicable, list any other providers where owners have a controlling interest.
In Section III: Subcontractor Ownership, indicate if your entity has a Direct or Indirect Ownership Interest in any subcontractors and provide necessary details.
Complete Sections IV through VII by providing information on familial relationships, criminal convictions, business transactions, and management/control details as prompted.
Review all entries for accuracy before submitting. Attach any additional sheets if necessary and ensure that all required fields are filled out correctly.

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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 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.

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

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.