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South carolina disclosure of ownership form 2026

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The document outlines the requirements for Medicaid providers to disclose ownership and control interests as mandated by federal regulations. It details the necessary information that must be provided, including names, addresses, and Social Security Numbers of individuals with ownership stakes, as well as any criminal offenses or sanctions related to those involved in the provider entity. The form must be completed for enrollment in the Medicaid program and submitted within specified timeframes, with consequences for non-compliance.

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Click ‘Get Form’ to open the South Carolina Disclosure of Ownership form in our platform.
Begin by filling out Section I, which requires identifying information such as the name of the provider, address, and NPI. Ensure all details are accurate and up-to-date.
In Section II, disclose ownership and control interests. List individuals or organizations with a direct or indirect ownership interest of 5% or more. Attach additional pages if necessary.
Proceed to Section III to list any subcontractors where you hold a direct or indirect ownership interest. Provide their names and relevant details.
Complete Sections IV through IX by answering questions regarding relationships, managing employees, criminal offenses, sanctions, and changes in provider status. Be thorough in your responses.
Finally, review all sections for accuracy before signing at the end of the form. Use our editor's features to ensure clarity and correctness.

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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 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

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.

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.

What is a disclosing entity in Medicaid?

Disclosing entity means a Medicaid Provider (other than an individual practitioner or group of practitioners), or a Fiscal Agent. For purposes of the Contract, Disclosing Entity means the Contractor.

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