Provider & Subcontractor Disclosure of Ownership & Controlling Interest Worksheet To comply with Federal law (42 CFR 455.100 106), health plans with Medicaid business must obtain certain information.
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How to fill out the 42 Cfr 455100 106 Form online
This guide provides a clear, step-by-step process for completing the 42 Cfr 455100 106 Form online. By following these instructions, users can ensure they meet the necessary requirements for participation with Medicaid health plans.
Follow the steps to complete the form accurately.
- Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
- Begin by filling in the identifying information of the Provider/Subcontractor. This includes the name, type of provider, tax ID, NPI number, and Medicaid provider ID. Ensure all details are accurate.
- Provide the primary business address of the provider/subcontractor. If there are changes in affiliation with the Tax ID number, mark the appropriate checkbox.
- List any additional business locations and specify the type of ownership. Examples include partnership, corporation, or government. Be precise in your descriptions.
- In the Disclosure of Ownership & Control Interest section, detail any individuals or organizations with a 5% or greater ownership interest. Include necessary information such as addresses, tax IDs, and if they are affiliated with other entities.
- For each person listed with an ownership interest, indicate their relationship to other owners (e.g., spouse, parent) in the corresponding section.
- Provide names of any additional disclosing entities related to the individuals with ownership interests in part (c) of this section.
- List managing employees, including their addresses, dates of birth, and social security numbers, who exercise operational control over the entity.
- Check if there have been any changes in ownership or control within the last year and provide the necessary dates if applicable.
- Answer whether any person listed has been excluded from Federal health programs or faced legal penalties, if so, document their details.
- Finally, review the completed form to confirm all information is accurate, and provide your signature, date, and title where specified. Ensure you indicate if additional information is attached.
- Once all fields are completed, save your changes, download a copy, print it for your records, or share the completed form as required.
Complete your 42 Cfr 455100 106 Form online now to ensure compliance and continue your Medicaid participation.
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