Clia disclosure of ownership form texas 2026

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The document is a Disclosure of Ownership and Control Interest Statement from the California Department of Public Health, requiring entities to provide identifying information and answer questions regarding ownership, control interests, and any criminal convictions related to Medicare/Medicaid programs. It includes sections for listing individuals or organizations with ownership stakes, changes in ownership or management, and affiliations with other facilities. The document emphasizes the importance of accurate disclosure to avoid legal repercussions.

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Click ‘Get Form’ to open the CLIA Disclosure of Ownership Form in our editor.
Begin by filling out the Identifying Information section. Enter the name of your entity, doing business as (D/B/A), address, city, CLIA number, taxpayer ID number (EIN), state, ZIP code, and telephone number.
Proceed to Section II. Answer the questions regarding ownership and control interest by checking 'Yes' or 'No'. If you answer 'Yes' to any question, provide additional details in the Remarks section on page 2.
In Section III, list names and addresses for individuals or EINs for organizations with direct or indirect ownership. Specify the type of entity and include any relevant information about other Medicare/Medicaid facilities.
Complete Sections IV through VII by answering questions related to changes in ownership, management affiliations, and operational status. Ensure all responses are accurate to avoid potential legal issues.
Finally, review your entries for accuracy before signing and dating the form at the bottom. Use our platform's features to save or share your completed document easily.

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What is a CMS 116 form?

CMS 116. Form Title. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION. Revision Date.

Where do I send my CMS 116 form?

Send the completed Form CMS-116 to the appropriate State Agency ( Legislation/CLIA/Downloads/CLIASA. pdf). Once the completed Form CMS-116 has been returned to the applicable State agency and it is processed, a fee remittance coupon will be issued.

How do I change ownership of a CLIA certificate of waiver?

Can I transfer my CLIA certificate to the new owners? Yes. The new owners can request a transfer by completing a CMS-116 Application Form and a CLIA Ownership Information form found under CERTIFICATION FEES on webpage.

What is disclosure of ownership for CAQH?

The CMS 1513 form serves as a critical disclosure document for revealing ownership and control interests in entities participating or seeking to participate in programs under the Department of Health and Human Services, including Medicare and Medicaid.

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

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What is a disclosure form?

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.

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.

Clia disclosure of ownership form texas 2026

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