Get Ownershipcontrolling Interest And Conviction - Colorado

Filling out the Ownership Controlling Interest and Conviction Disclosure Form is a crucial step for providers seeking to enroll in the Colorado Medical Assistance Program. This guide will walk you through the process of completing the form online with clarity and ease.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to obtain the document and open it for editing.
2. Begin by entering your legal name, provider number, and any applicable doing business as (dba) name in the respective fields.
3. Provide your Employer Identification Number (EIN) or Social Security Number (SSN) in the next section.
4. Fill in your contact details including street address, telephone number, fax number, city, state, and zip code.
5. Include your National Provider Identifier (NPI) if applicable, and your email address for further correspondence.
6. Select the appropriate business entity type, such as partnership, limited liability partner, or corporation by checking the relevant box.
7. Complete Field A by listing the names, addresses, SSNs/EINs, and dates of birth of every person or corporation with an ownership or control interest.
8. If applicable, detail any subcontractors with a 5% or greater ownership interest in Field B.
9. Indicate any familial relationships among the persons listed in Fields A and B in Field C.
10. List the names and information of managing employees in Field D, adding additional sheets if required.
11. In Field E, disclose any overlapping ownership interests with other providers.
12. Complete Field F by reporting any individuals with a criminal conviction as described, or check 'None' if not applicable.
13. Review all entries for accuracy and completeness before finalizing your submission.
14. After filling out all sections, save your changes, download the completed form, print it, or share it as needed.

Complete your Ownership Controlling Interest and Conviction Disclosure Form online today for streamlined provider enrollment.