Get Clia Disclosure Of Ownership & Control Interest Statement (form ... - Health Nv

The CLIA Disclosure Of Ownership & Control Interest Statement is an essential document for health facilities seeking to comply with regulations. This guide provides clear, step-by-step instructions on how to accurately complete the form online, ensuring that your submission meets all necessary requirements.

Follow the steps to accurately complete the form.

1. Use the ‘Get Form’ button to obtain the CLIA Disclosure Of Ownership & Control Interest Statement. This will allow you to access the form and begin filling it out.
2. In Section I, provide the identifying information of your entity. This includes the name of the entity, doing business as (D/B/A) name, street address, CLIA number, employer identification number (EIN), telephone, and fax numbers. Ensure that all entries are accurate and complete.
3. Continue to Section II. Answer each of the questions by checking 'Yes' or 'No'. If any questions are answered 'Yes', provide the names and addresses of individuals or corporations in the remarks section on page 2. Be sure to identify each item by its number to ensure clarity.
4. In Section III, for each of the ownership or control interest inquiries, provide details about directors or individuals associated with your entity as prompted. If your entity is a corporation, list all relevant directors and engage the remarks section for additional comments.
5. In Section IV, answer the questions regarding any changes in ownership or control, anticipated changes, and bankruptcy filings. Provide dates where applicable.
6. Section V requires you to indicate if the facility is operated by a management company or partially leased by another organization. Make sure to answer these questions honestly.
7. Complete Sections VI and VII, detailing any changes in directors or affiliation with a chain. Be specific and provide additional names and addresses in the remarks if necessary.
8. Finally, sign the document where indicated, providing the name of the authorized representative, their title, and the date of signing. Before submitting, review the entire form to ensure all information is correct and complete.
9. Once completed, you can save changes, download, print, or share the form as needed to complete your submission.

Start filling out your CLIA Disclosure Of Ownership & Control Interest Statement online today for a smooth and compliant application process.