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Deleware disclosure statement medicaid 2025

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The document provides instructions for completing the Provider Disclosure Statement required by the Delaware Division of Medicaid & Medical Assistance (DMAP) for all providers enrolling in the program. It outlines definitions related to ownership, control interests, and significant business transactions, as well as specific questions that must be answered regarding criminal convictions, business transactions with subcontractors, and ownership interests. The document emphasizes the importance of accurate disclosure to avoid penalties or termination from the Medicaid program.

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Click ‘Get Form’ to open the Delaware Disclosure Statement Medicaid in the editor.
Begin by entering the 'Name of Entity / Individual' and 'Address' in the designated fields. Ensure that all information is accurate to avoid delays.
Fill in your 'EIN / SSN', 'NPI', and 'Taxonomy'. These identifiers are crucial for processing your application.
Answer questions 1 through 3 carefully. For each question, indicate 'YES' or 'NO' and provide additional details as required, especially if you answer 'YES'.
For questions 4 to 6, provide names and addresses of individuals with ownership or control interests. Be sure to clarify relationships where applicable.
Review all entries for accuracy before signing. Use our platform's features to save your progress and make edits as needed.

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What is a Medicaid 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 documentation is required for Medicaid in Delaware?

There are also many assets that are non-countable; they are exempt. Exemptions include personal belongings, such as clothing, household furnishings, an automobile, up to $1,500 for burial, an irrevocable funeral trust up to $15,000, life insurance with a combined face value of $1,500, and generally ones primary home.

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