Get Ky Chfs Ado 2013-2025

The Annual Disclosure of Ownership (ADO) form is a critical document required by federal and state regulations for Medicaid providers in Kentucky. This guide will provide you with a step-by-step approach to completing the KY CHFS ADO online, ensuring that you understand each section and can submit your form accurately.

Follow the steps to complete the ADO form effectively.

1. Click ‘Get Form’ button to access the ADO form and open it for editing.
2. In the first field, enter the name of the individual or entity to whom the ADO pertains.
3. Input the KY Medicaid provider number associated with the ADO.
4. Indicate whether you anticipate any changes in ownership, management company, or control within the following year, and provide specific details if applicable.
5. If you foresee filing for bankruptcy within the same year, state the anticipated date of filing.
6. For those who are part of a corporate structure, input the Federal Tax Identification Number and provide the name, address, city, state, and zip code of the affiliated entity.
7. List each person or organization with a direct or indirect ownership interest of 5% or more in the disclosing entity, providing all necessary details. If no one qualifies, check the corresponding box.
8. Enter the information for all officers and board members of the disclosing entity. Attach additional pages if necessary.
9. Provide details about any management company applicable to your situation, or mark as N/A.
10. Disclose the names of any other disclosing entities in which individuals from your entity hold ownership.
11. Report any significant business transactions with other Medicaid providers if they exceed $25,000 or 5% of total operating expenses during any fiscal year.
12. List any significant business transactions with wholly owned suppliers or subcontractors from the last five years.
13. Provide details about immediate family members authorized to prescribe medical services.
14. Indicate any individuals or organizations with ownership interests who have been convicted of a relevant criminal offense, providing necessary identifiers.
15. List any agents or managing employees who have a criminal conviction relevant to Medicaid programs.
16. Enter information for all managing employees as defined by regulations.
17. Document subcontractor details for individuals with any direct or indirect ownership interests exceeding 5%.
18. Specify the number you will use for IRS reporting of Medicaid payments, opting for either your FEIN or SSN as appropriate.
19. Initial to certify that you maintain electronic medical records and comply with HIPAA regulations; check the box if you do not.
20. Provide your contact information in case there are questions about your form.
21. Finally, ensure you sign the form, print your name, and date it. The title of the person signing should also be included.
22. Once completed, save any changes, and download, print, or share your form as needed.

Complete your KY CHFS ADO form online now to ensure compliance and avoid delays in processing.