Caqh la printable disclosure information page 2025

1. Click ‘Get Form’ to open the caqh la printable disclosure information page in the editor.
2. Begin by filling out the Practice Information section. Select whether you are an Individual, Group Practice, or Disclosing Entity and provide your name, DBA Name, address, Federal Tax Identification Number, and Provider CAQH #.
3. In Section I, list all individuals with a control interest of 5% or greater. Include their name, title, address, date of birth (DOB), and Social Security Number (SSN). If necessary, attach a separate sheet for additional entries.
4. Proceed to Section II to indicate if any listed individuals are related. If yes, specify their names and type of relation.
5. In Section III, answer whether there are subcontractors with direct or indirect ownership of 5% or more. If applicable, provide details as requested.
6. Section IV requires you to disclose any convictions related to Medicaid or Medicare involvement. List relevant individuals if applicable.
7. For Section V, report any significant business transactions exceeding $25,000 with subcontractors over the past year.
8. Finally, confirm your status as a Disclosing Entity in Section VI and list Board members if applicable. Ensure all information is accurate before signing and dating the form.

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