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Federally required disclosures form

Pe frd in 2026

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The document outlines the federally required disclosures for individual practitioners seeking to provide services to MassHealth members in Massachusetts. It details the necessary information that must be submitted, including personal identification, service location, relationships with other entities, and any relevant legal or disciplinary history. The form emphasizes compliance with federal regulations and includes a certification statement for accuracy and completeness.

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Click ‘Get Form’ to open the pe frd in document in the editor.
Begin with Section 1: Practitioner Information. Fill in your legal name, National Provider Identifier Number (NPI), date of birth, and social security number (SSN). Ensure your home address, contact number, and email are accurate.
Proceed to Section 2: Primary Service Location (PSL) Information. Indicate if your PSL address is the same as your home address. If not, provide the PSL street address and contact details.
In Section 3, list any individuals or entities related to you that meet the specified criteria. If there are none, check 'NONE' and continue.
Answer the questions in Section 4 regarding disclosures. Provide detailed explanations for any 'yes' responses in Section 4B.
Finally, review and sign Section 5: Certification Statement. Ensure all information is true and complete before submitting.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (254 Votes)

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