Get In Form Hfs 1513 What Is Dba Name

The In Form Hfs 1513 is a crucial document required by the Illinois Department of Healthcare and Family Services for enrollment in the medical assistance program. Completing this form accurately online ensures that your application is processed without delays.

Follow the steps to fill out the In Form Hfs 1513 What Is Dba Name online easily and effectively.

1. Press the ‘Get Form’ button to obtain the document and open it in the suitable editor.
2. In the first section labeled 'Identifying Information', provide your provider name, NPI, provider number, DBA name, office street address, telephone number, zip code, city, county, and state. Make sure all details are accurate as they are essential for your enrollment.
3. In section 2(a), list the name, address, and SSN or EIN of each person or entity with direct or indirect ownership or control interest in the disclosing entity, including any subcontractors where you have a 5% or more ownership share. Use the ‘Remarks’ area on page 2 for additional names.
4. For section 2(b), if any individuals listed in section 2(a) are related to each other, indicate the nature of the relationship using common terms such as spouse, parent, or sibling.
5. In section 2(c), check the appropriate type of entity you are representing, such as 'Sole Proprietorship', 'Partnership', 'Corporation', or any other specified entity.
6. Next, list the names, addresses, and SSNs of the directors, officers, partners, and managing employees of the disclosing entity in section 2(d). Again, use the ‘Remarks’ field for any additional entries.
7. Section 3 requires you to indicate if there has been a change in ownership or control for the disclosing entity within the last year, providing details where applicable, including the prior owner's name and date of change.
8. In section 4, you will need to list any person with ownership or control interest in the disclosing entity, or an agent or managing employee, who has been convicted of a criminal offense.
9. Section 5 focuses on listing any individuals with ownership or control who have been sanctioned by any healthcare-related program since the inception of those programs.
10. In the final section, ensure to include the name of the authorized representative, their title, provide a signature, and date the document. Review all fields for accuracy.
11. After completing all steps, save your changes, and you have the option to download, print, or share the form as needed.

Complete the In Form Hfs 1513 online today to ensure your medical assistance enrollment is processed without delay.