Get Valueoptions Disclosure Of Ownership Form

This guide provides a step-by-step approach to filling out the ValueOptions Disclosure Of Ownership Form online. It aims to support users in completing the necessary sections accurately to comply with Federal law.

Follow the steps to complete the form efficiently.

1. Press the ‘Get Form’ button to retrieve the ValueOptions Disclosure Of Ownership Form and open it in your preferred editor.
2. Begin with section I, Identifying Information. Fill in the name of the individual completing the form, their contact phone number, and details about the Provider Entity, such as Provider Name, Entity Name, NPI number (if applicable), and Federal Tax ID number. Ensure to also add the DBA name, Medicaid ID number, and the full address, including city, state, and zip code.
3. Move to section II, Owner or Control Information. In part A, create a Master List by providing names, addresses, and ownership percentages for all individuals and entities with stake in the Provider Entity. Include relevant Social Security Numbers (SSN) or Tax IDs where necessary.
4. In part B, answer specific questions regarding any relationships among individuals listed in the Master List, any ownership interests in other Provider Entities, and any criminal convictions, debarments, or exclusions related to Medicare or Medicaid services.
5. Continue to section III, Business Transactions. Here, list any subcontractors involved in business transactions that meet the specified financial criteria over the past five years, and answer questions about supplier ownership.
6. Finally, complete section IV by providing your printed name, signature, title, and the date. Ensure that the individual signing is authorized to bind the Provider Entity.
7. After filling out all sections, save your changes. You may then download, print, or share the completed form as required.

Start filling out your ValueOptions Disclosure Of Ownership Form online today!