Get Disclosure Of Ownership Business Transactions & Exclusions Statement For Providers
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How to fill out the Disclosure of Ownership Business Transactions & Exclusions Statement for Providers online
Filling out the Disclosure of Ownership Business Transactions & Exclusions Statement for Providers is a crucial step in maintaining compliance with managed care organizations. This guide provides you with an easy-to-follow process to complete this form accurately and effectively.
Follow the steps to accurately complete the Disclosure of Ownership Business Transactions & Exclusions Statement.
- Press the ‘Get Form’ button to access the form and open it in your editor.
- Begin by entering your identifying information including your legal name according to the IRS, doing business as (DBA) name, and your address. Ensure that you also fill in your office phone number, federal employer ID (FEIN), and tax ID.
- Indicate your business structure by checking the appropriate box that describes your entity. Options include sole proprietorship, partnership, corporation, limited liability corporation, non-profit, or other partnership.
- For ownership and control interests, list each person with an ownership or control interest in your organization. Fill out their full legal name, address, percentage of ownership interest, social security number or FEIN, driver's license number, and relationship.
- If any persons listed have familial relationships to others in the ownership section, document these relationships in the following section, indicating full legal names, addresses, percentage of ownership interest, social security numbers or FEIN, driver's license numbers, and the nature of their relationship.
- Provide details of any significant business transactions with subcontractors exceeding $25,000 in the previous twelve months. List the name of the subcontractor, their address, social security number or FEIN, and percentage of ownership interest.
- Report any significant business transactions that occurred within the last five years between your organization and wholly owned suppliers or subcontractors, including their names, addresses, social security numbers or FEIN, and the nature of the business transaction.
- Answer the questions regarding excluded individuals or entities involved with ownership, control, or management. Indicate whether they have been convicted of criminal offenses or excluded from participation in government health care programs.
- For each individual or entity that falls under exclusions, provide their names, addresses, social security numbers or FEIN, and the reasons for your affirmative responses.
- Finally, certify that all information provided is true and correct. Fill in your name, title, signature, date, and email address to complete the form.
- After reviewing all provided information, save your changes. You can then download, print, or share the form as needed.
Complete your Disclosure of Ownership Business Transactions & Exclusions Statement online today for a smooth process!
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The disclosure of ownership form is a document that outlines the ownership structure of a business and is essential for regulatory compliance. It specifically details individuals or entities that hold ownership or control interests, which aids in transparency and accountability. Utilizing the Disclosure of Ownership Business Transactions & Exclusions Statement for Providers can help businesses navigate complex ownership issues and maintain trust with stakeholders.
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