Get Unitedhealthcare Provider Entity Disclosure Form 2015
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the UnitedHealthcare Provider Entity Disclosure Form online
The UnitedHealthcare Provider Entity Disclosure Form is a critical document for providers involved in Medicaid and CHIP programs. This guide will provide you with clear, step-by-step instructions to help you efficiently complete the form online.
Follow the steps to accurately complete the disclosure form.
- Click 'Get Form' button to obtain the form in an editable format.
- Fill out the Contracted Provider Entity Information section completely. Ensure every field is filled out to prevent processing delays.
- Select the type of disclosing entity that applies to your organization by checking the appropriate box.
- Provide the name of the person completing the form along with their title, phone number, fax, and email address.
- Indicate the state in which you participate in Medicaid and provide the legal name of the Provider Entity.
- Enter any 'Doing Business As' (DBA) name if it differs from the legal name.
- Complete the address fields thoroughly, listing all business locations, including street, city, state, and ZIP codes.
- Fill out the required fields for Federal Tax ID, Medicaid ID, National Provider ID, and CAQH number.
- In Section I, provide information about any individuals or organizations with a Direct or Indirect Ownership or Controlling Interest of 5% or more.
- Proceed to Section II to disclose ownership interests in other providers or entities, if applicable.
- Continue to Section III to report Direct or Indirect Ownership Interests in any Subcontractors.
- In Section IV, indicate any familial relationships among owners listed in previous sections.
- Complete Section V to provide details regarding any criminal convictions, sanctions, exclusions, or debarments for relevant individuals.
- Fill out Section VI, detailing business transactions totaling over $25,000 with subcontractors within the past year.
- In Section VII, provide information on Managing Employees, Agents, and Board of Directors, if applicable.
- Review the completed form for accuracy and ensure that all required fields are filled in. Attach any necessary documents and indicate their relevant sections.
- Save your changes, then download, print, or share the completed form as needed.
Complete the UnitedHealthcare Provider Entity Disclosure Form online to maintain compliance and ensure your participation in important Medicaid and CHIP programs.
Get form
A health disclosure form is a document used to communicate a patient’s consent for the release of their personal health information. This form is essential for compliance with healthcare laws and regulations, ensuring that patient privacy is maintained. To streamline your understanding and usage of this form, refer to the UnitedHealthcare Provider Entity Disclosure Form for clear instructions and details.
Get This Form Now!
Industry-leading security and compliance
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.