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Person of Interest Entity Disclosure Form 2026

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The document is a Person of Interest Entity Disclosure Form required by the Montana Medical Marijuana Program. It must be completed for each entity applying for a medical marijuana license, detailing ownership structure, financial interests, and personal information of individuals involved. The form emphasizes that submission does not guarantee approval and outlines the need for additional documentation as per state regulations.

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Click ‘Get Form’ to open it in the editor.
In Section A, enter your Canopy License Number if applicable, followed by the Business Name and the Name of the entity applying as a Person of Interest.
Proceed to Section B. Specify the Type of Entity or Person Applying (e.g., Sole Proprietor, LLC) and provide the Assumed Business Name (DBA) along with the FEIN. If you are a Sole Proprietor without hired staff, indicate N/A.
In Section C, list all owners, partners, and members. Include their SSN for individuals and FEIN for entities. Ensure that each individual submits fingerprint cards and a signed Privacy Act Statement.
Section D requires you to disclose any financial interests related to other medical marijuana licenses. Answer each question accurately and attach additional pages if necessary.
Finally, in Section E, declare that all information is true by signing and dating where indicated. Ensure all required signatures are collected before submission.

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2020	4.8 Satisfied (32 Votes)

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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.

What is an example of a disclosing entity?

Examples of Disclosing entity in a sentence Disclosing entity means a Medicaid provider (other than an individual practitioner or group of practitioners), or a fiscal agent. The Receiving entity hereby acknowledges that the Confidential Information is proprietorship of the Disclosing entity.

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.

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What is a business disclosure form?

Disclosure is when a company or corporation informs its customers, investors, and analysts involved in doing business with the company, of pertinent information. Federal regulations require publicly traded companies to disclose relevant financial information to shareholders.

Who is a person with an ownership or control interest?

The definition of person with an ownership or control interest includes one who is an officer or director of a disclosing entity that is organized as a corporation. 42 CFR section 455.101. Thus, State Medicaid agencies must collect disclosures from all provider applicants regardless of for-profit status.

What is a Form 1513 disclosure of ownership?

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.

Person of Interest Entity Disclosure Form 2026

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How to use or fill out Person of Interest Entity Disclosure Form

See more Person of Interest Entity Disclosure Form versions

Complete this form in 5 minutes or less

Got questions?

Can I sign my person of interest template with my phone?

How do you create an e-signature for the application form documents on iOS?

What is disclosure of ownership for CAQH?

What is an example of a disclosing entity?

What is an ownership disclosure form?

Security and compliance

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What is a business disclosure form?

Who is a person with an ownership or control interest?

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