Get Amerigroup Disclosure Form

The Amerigroup Disclosure Form is a vital document for provider entities applying for network participation, recredentialing, or reporting significant changes. This guide outlines the steps to complete the form online efficiently and thoroughly.

Follow the steps to complete the Amerigroup Disclosure Form accurately.

1. Press the 'Get Form' button to access the Amerigroup Disclosure Form. This will allow you to retrieve the document in an editable format.
2. Begin with Section I, Identifying Information. Fill out required fields, including Provider DBA Name, Provider Entity Name, Provider Federal Tax ID Number, Provider NPI number, and Provider Medicaid ID number. Ensure you provide your organization’s phone number and physical address, listing all practice locations clearly.
3. Move to Section II, Owner or Control Information. Here, submit details for individuals or entities owning 5 percent or more of the provider entity. Complete the Master List with full names, addresses, dates of birth, and Social Security numbers or Tax IDs. Indicate the percentage of ownership and titles for each individual listed.
4. In the Specific Questions subsection of Section II, respond to inquiries regarding relations among individuals on the Master List, criminal convictions, debarments, exclusions from health programs, terminations, civil monetary penalties, and ownership interests. Provide additional details as required.
5. Proceed to Section III, Business Transactions. Indicate if any significant financial transactions occurred with subcontractors exceeding $25,000. If applicable, list the name, address, and relevant details of the subcontractors involved.
6. Complete Section IV, Signature. This part requires the printed name, signature, title, and phone number of the person completing the form. This person's signature must be one that can legally bind the provider entity.
7. Once all sections are completed, review the form for accuracy. Save your changes, and you may download, print, or share the document as necessary.

Start filling out the Amerigroup Disclosure Form online to ensure your application for network participation is processed smoothly.