Get Disclosure Of Ownership And Control Interest Statement - Aging Ks

This guide provides comprehensive, step-by-step instructions for filling out the Disclosure Of Ownership And Control Interest Statement - Aging Ks online. It is designed to assist users, regardless of their prior experience with legal documents.

Follow the steps to complete the form carefully and accurately.

1. Click the ‘Get Form’ button to download the Disclosure Of Ownership And Control Interest Statement - Aging Ks document and open it in a suitable online editor. This will allow you to interact with the fields directly.
2. Begin by entering the name of the entity or individual, along with their address. Be sure to accurately provide the Employer Identification Number (EIN) or Social Security Number (SSN) as needed, and include the date of birth if the individual is listed.
3. Fill out the section for the National Provider Identifier (NPI), ensuring that all relevant address details, including city, state, and zip code, are correctly entered.
4. Questions 1 through 3 must be completed by fiscal agents and all providers except individual practitioners. Carefully list each person or corporation with ownership or control interest, providing all requested details such as name, address, date of birth (if applicable), and Social Security Number.
5. Designate any relationships between individuals listed in Question 1 by detailing the names and relationships, such as spouse or sibling, where applicable.
6. In response to Question 3, identify if any individuals listed have ownership interests in other Medicaid providers or entities that require disclosure. Provide the necessary details requested.
7. For group providers, answer Question 4 regarding relationships with group physicians and provide the required information.
8. Complete Questions 5 through 15 accurately, addressing each point such as previous convictions, business transactions, and information about managing employees. For any 'yes' responses, ensure that additional information is provided, and any required documentation is attached.
9. Finally, provide contact information for audit purposes and the physical location of records that need to be maintained per state regulations. Ensure all details are correctly filled out.
10. After reviewing all entries for accuracy, you may save changes, download, print, or share the completed form as needed.

Complete your documents online today to ensure compliance and accuracy.