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Get Federally Required Disclosure Form Mass Health
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How to fill out the Federally Required Disclosure Form Mass Health online
Filling out the Federally Required Disclosure Form for Mass Health is a crucial step for providers and disclosing entities. This guide provides a clear and supportive approach to completing the form online, ensuring compliance with federal requirements.
Follow the steps to successfully complete the form online.
- Press the ‘Get Form’ button to access the Federally Required Disclosure Form and open it in your preferred editor.
- Begin by completing the identification information section. Provide the name and address of the applicant, whether an individual or a legal entity, and make sure to include a contact person and their details.
- Move on to Section IV.A for Ownership and Control disclosures. Here, list any person or entity with ownership interests and provide requested information, ensuring to attach details if more space is needed.
- In Section IV.B, confirm relationships among individuals with ownership or control interests if applicable. This includes identifying related parties like spouses or siblings.
- Proceed to Section IV.C if you've received direction from MassHealth regarding business transactions. Identify any subcontractors with significant business transactions exceeding $25,000.
- Complete Section IV.D, which deals with criminal convictions. Provide information on any individual with ownership interests or who is a managing employee who has criminal convictions if not otherwise directed by MassHealth.
- If applicable, fill out Section IV.E regarding relationships to excluded, penalized, or convicted persons. Provide details about any such individuals according to the laid-out definitions.
- Finally, review the attestation section in Section IV.F. Ensure all information has been reviewed and confirm accuracy by providing a signature and date. After completion, save the changes, and choose options to download, print, or share the form.
Complete the Federally Required Disclosure Form online to ensure compliance with MassHealth regulations.
Federal law requires fiscal agents, managed care entities (MCEs), and other MassHealth providers, including applicants and certain bidders seeking to provide MassHealth services, to disclose some or all of the following: business ownership and control, business transactions, and criminal convictions.
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