Get Enter Name Of Individual Or Entity Depending On Who The Disclosure Is In Regards To - Chfs Ky

Filling out the Enter Name Of Individual Or Entity Depending On Who The Disclosure Is In Regards To - Chfs Ky form is essential for ensuring compliance with state regulations regarding ownership disclosures. This guide will walk you through each section of the form to facilitate a smooth and accurate completion.

Follow the steps to effectively complete the disclosure form.

1. Click ‘Get Form’ button to access the document and open it for filling out.
2. In the first field, enter the name of the individual or entity that the disclosure pertains to, ensuring that it accurately reflects the legal designation.
3. Next, provide the KY Medicaid provider number related to the individual or entity. It is imperative to have the correct number to avoid delays.
4. Indicate if you expect any ownership changes, management structure changes, or control shifts in the coming year. If applicable, specify the date of the anticipated change.
5. If filing for bankruptcy is a possibility, please provide the expected date in the designated field.
6. Enter the Federal Tax Identification Number if applicable, along with the name, address, city, state, and zip code of the affiliated chain.
7. List all individuals or entities with a 5% or more ownership or control interest. If no individual meets this criterion, check the corresponding box.
8. Provide details of any officers and board members of the disclosing entity, ensuring to list the complete first names without initials.
9. If any individuals listed previously are related by family, please disclose their relationship.
10. If applicable, provide the name and contact information of the management company associated with the disclosing entity.
11. Detail any significant business transactions over the last year, especially those involving a total transaction value exceeding $25,000 or 5% of your operating expenses.
12. List any immediate family members authorized to prescribe medications and provide their details.
13. Indicate if any individuals or organizations listed have been convicted of criminal offenses related to healthcare programs.
14. Fill in contact information for any queries regarding the form, ensuring accuracy for follow-up.
15. Sign and date the form in the designated sections, ensuring that the signature is from the individual provider or responsible entity.
16. Finally, review all sections for completeness, ensuring no blank fields remain. Save your changes, then download, print, or share the form as needed.

Complete the disclosure form online to ensure compliance with Medicaid regulations.