Get Az Ahcccd Disclosure Ownership Form 2012-2025
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 AZ AHCCCD Disclosure Ownership Form online
This guide provides detailed instructions for filling out the AZ AHCCCD Disclosure Ownership Form online. By following these steps, individuals can ensure they accurately provide the required information for compliance with AHCCCS regulations.
Follow the steps to successfully complete the form online.
- Click ‘Get Form’ button to obtain the form and open it in the online editor.
- Begin with Item I, which contains identifying information. Fill in the name of the individual, facility, or organization in the designated field. Include the DBA (Doing Business As) name if applicable. Enter the federal tax identification number or social security number accordingly.
- Provide ownership and control interest information in Item II. For subsection (a), list all individuals and entities with 5% or more ownership interest, including their names, titles, addresses, TINs, dates of birth, and ownership percentages. Use attachment A if more space is needed.
- For subsection (c), list individuals with ownership or control interest in any subcontractor where the disclosing entity has 5% or more ownership. Include their names, titles, addresses, and social security numbers.
- In subsection (d), identify relationships among the individuals listed in previous sections (such as spouse, parent, child, or sibling) including names and relationships.
- Complete subsection (e) by listing any disclosing entity in which a person with an ownership interest also has 5% or more ownership interest. Provide names, addresses, TINs, and percentages.
- Proceed to Item III and provide criminal offenses information for individuals with ownership or control interests in the disclosing entity. List their names, titles, addresses, and SSNs if applicable.
- In Item IV, list the members of the Board of Directors of the disclosing entity by providing their names, titles, and addresses.
- Finalize the form by affirming the truth and accuracy of provided information. Print the name and title of the authorized representative, sign the form, and include the date.
- Once the form is completed, save your changes. You may download, print, or share the form as needed for your records.
Complete your AZ AHCCCD Disclosure Ownership Form online today to ensure compliance and accuracy.
The disclosure of ownership for CAQH relates to the requirement for healthcare organizations to reveal their ownership structures and affiliations. By completing this disclosure, which aligns with the AZ AHCCCD Disclosure Ownership Form, organizations can streamline their enrollment processes with insurance companies. Accurate ownership information helps enhance communication and builds credibility within the healthcare community.
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.