Get Nh Healthy Families Dsclosure Of Ownership Form

Completing the Nh Healthy Families Disclosure Of Ownership Form online is essential for ensuring compliance with federal regulations. This guide will provide you with clear, step-by-step instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to access the form and open it in your designated editor.
2. In the practice information section, check the box that best describes your practice. Enter the full practice name, any DBA name if applicable, and provide the practice address, Federal Tax ID number, and Provider CAQH number in the relevant fields.
3. Move to Section I, where you need to provide detailed ownership information of your practice or business. List all individuals or entities with an ownership or control interest of 5% or greater. Ensure you fill in their names, titles, addresses, dates of birth, and Social Security numbers or Tax Identification numbers as required.
4. Proceed to Section II, where you will indicate if any individuals listed in Section I are related. Check ‘Yes’ or ‘No’ and provide the names and types of relationships if applicable.
5. In Section III, identify whether there are any subcontractors with 5% or more ownership interest by checking ‘Yes’ or ‘No.’ If ‘Yes,’ you must list the name and address of each relevant subcontractor.
6. Continue to Section IV, where you will state if any individual with ownership or control has ever been convicted of a crime related to Medicaid or Medicare programs. Again, check 'Yes' or 'No' and provide detailed information if 'Yes.'
7. In Section V, report any financial transactions with subcontractors totaling more than $25,000 or any significant business transactions with them from the past five years. Indicate 'Yes' or 'No' and supply the required details if applicable.
8. If your practice is classified as a Disclosing Entity, go to Section VI. Check ‘Yes’ and list each member of the Board of Directors or Governing Board, including their name, DOB, address, SSN, and percent of interest. If not, select ‘No.’
9. Finally, ensure that you sign and date the form. Include your printed name and title. Review the completed form for accuracy before submitting it.
10. Once you have filled out all necessary sections, save your changes. Depending on your preference, you can download, print, or share the form.

Start filling out the Nh Healthy Families Disclosure Of Ownership Form online today to ensure your compliance.