Get Mltc 62 Form

The Mltc 62 Form is an essential document required by the Centers for Medicare and Medicaid Services. This guide will provide you with step-by-step instructions to help you efficiently complete the Mltc 62 Form online, ensuring that you meet the necessary regulatory requirements.

Follow the steps to successfully complete the Mltc 62 Form online.

1. Click the ‘Get Form’ button to access the Mltc 62 Form and open it in your preferred online editing tool.
2. In the identifying information section, enter the name of the entity as it appears on the tax identification form. Provide the provider number if currently enrolled in Nebraska Medicaid. Also, include the 'Doing Business As' name and NPI number. Fill out the street address, city, state, zip code, telephone number, fax number, and email address.
3. If the entity is a government organization or a non-profit, check the box indicated and proceed to fields C, D, and E.
4. Under section A, list the names, addresses, federal employer identification numbers (FEIN) or social security numbers (SSN), and dates of birth (DOB) for each person with ownership or control interest in the disclosing entity. Specify the percentage of interest for each.
5. In section B, indicate whether any of the individuals listed in section A are related to each other. If yes, provide their names, SSNs, relationships, and DOBs.
6. In section C, document the names, SSNs, positions, and DOBs of persons who hold a position of managing employee within the entity.
7. In section D, answer whether any individual or business with ownership mentioned has a controlling interest in any other Nebraska Medicaid provider. If yes, include the relevant details.
8. In section E, list any individual who has an ownership interest or is an agent/employee of the entity and has been convicted of any relevant criminal offense. Include the necessary information for each individual.
9. Carefully read the provider statement and sign where indicated. Include the printed name, date, and contact phone number.
10. Once all sections are complete, save your changes, and then choose to download, print, or share the completed Mltc 62 Form as required.

Complete your Mltc 62 Form online today to ensure compliance with essential regulations.