Get Unitedhealthcare Provider Entity Disclosure Form 2016-2025

Filling out the UnitedHealthcare Provider Entity Disclosure Form is an essential step for providers participating in Medicaid and CHIP programs. This guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently online.

Follow the steps to complete the UnitedHealthcare Provider Entity Disclosure Form online.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred format.
2. Begin with the contracted provider entity information section. Make sure to fill in all fields completely. Failure to do so will result in the form being returned for corrections.
3. Select the type of disclosing entity from the options provided, such as partnership, non-profit, corporation, limited liability corporation (LLC), or government/public entity.
4. Complete the section for personal contact details including the name of the person completing the form, their title, and contact information such as phone number, fax, and email.
5. Specify the state in which you participate in Medicaid. Provide the legal name of the provider entity, any doing business as (DBA) name, and the complete address.
6. List any additional addresses if applicable, and provide the necessary federal tax ID, Medicaid ID, national provider ID (NPI), and CAQH number. Remember, some fields cannot remain blank.
7. Move to Section I and identify all owners with direct or indirect ownership of 5% or more in the provider entity. Attach any necessary lists.
8. In Section II, identify all individuals and entities with a controlling interest by providing their relevant details, including names, addresses, and personal identification numbers.
9. Proceed to Section III to note any owners with ownership or controlling interest in other disclosing entities, followed by identifying similar interests in subcontractors in Section IV.
10. Complete Section V, which pertains to familial relationships among individuals identified in previous sections.
11. Address criminal convictions, sanctions, exclusions, and terminations in Section VI, ensuring you include all required details.
12. In Section VII, report any business transaction information related to subcontractors and suppliers as stated.
13. Finally, complete Section VIII, detailing managing employees and agents associated with the provider entity.
14. Once you have completed the form, review all entries for accuracy before submitting. You can save changes, download, print, or share your completed form.

Complete your UnitedHealthcare Provider Entity Disclosure Form online today to ensure compliance and continued participation.