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Tment of Health and Human Services. (Citation: 42 CFR 455.104, 455.105, and 455.106) to participate in the North Dakota Medical Assistance Program (Medicaid) as mandated. Failure to provide the social security number may result in a delay in processing the application. Disclosure must be made at the time of enrollment or contracting with the Department at time of survey, or within 35 days of a written request from the Department. I. Identifying Information The address for corporate entities m.

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Application Information All providers are required to apply for enrollment electronically on the ND Health Enterprise MMIS portal. The exception is Qualified Service Providers. All enrollment documentation submitted must include the application tracking number (ATN) from the online enrollment application.

Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.

Person with ownership or control interest means a person or corporation that: Has an ownership interest totaling 5 percent or more in a disclosing entity; Has an indirect ownership interest equal to 5 percent or more in a disclosing entity; Has a combination of direct and indirect ownership interests equal to 5 percent ...

Disclosure of Ownership and Control Interest Statement The information required includes, but it is not limited to, name, address, date of birth, social security number (SSN) and tax identification (TIN) as described in 42 CFR § 455.106.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232