Get Ca Anthem Disclosure Of Ownership And Control Interest Statement 2011-2025
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How to fill out the CA Anthem Disclosure of Ownership and Control Interest Statement online
Filling out the CA Anthem Disclosure of Ownership and Control Interest Statement is essential for providers entering into or renewing a provider agreement. This guide provides a clear, step-by-step approach to assist you in completing the form accurately and efficiently online.
Follow the steps to complete the form online effectively.
- Click ‘Get Form’ button to access the CA Anthem Disclosure of Ownership and Control Interest Statement. This will allow you to open the form in an editable format.
- Review the practice information section and select the option that best describes your status, whether as an individual, group practice, or disclosing entity. Fill in the name of the individual, group practice, or disclosing entity, along with the doing business as (DBA) name, address, federal tax identification number, and your Provider CAQH number.
- In Section I, provide the name, title, address, date of birth (DOB), and Social Security Number (SSN) for each individual with a 5% or greater ownership or control interest in your provider entity. If listing an entity, include the name, Tax Identification Number (TIN), and business address for each organization with the same ownership interest.
- Proceed to Section II to indicate whether any individuals listed are related. Select 'Yes' or 'No', and if 'Yes', specify the names and relationships between the individuals.
- In Section III, state whether there are any subcontractors for which the disclosing entity has a direct or indirect ownership of 5% or more. If applicable, provide the name, address, DOB, and TIN for each individual or entity with this ownership interest.
- Section IV requires you to disclose if anyone with an ownership or control interest, or who is a managing employee, has ever been convicted of a crime related to their involvement in Medicaid, Medicare, or Title XX programs. Select 'Yes' or 'No', and if 'Yes', list those individuals.
- For Section V, indicate if the disclosing entity has had any financial transactions with subcontractors totaling more than $25,000. If so, detail the ownership and provide specific transaction information required.
- Section VI asks if you identified your status as a Disclosing Entity. If 'Yes', list each member of the Board of Directors or Governing Board, including their name, DOB, address, SSN, and percent of interest.
- Finally, certify that all provided information is true and acknowledge that inaccuracies may affect participation. Include your signature, title, printed name, and date.
- After completing the form, you can save changes, download a copy, or print it for submission.
Complete your CA Anthem Disclosure of Ownership and Control Interest Statement online today.
To write a declaration of interest statement, begin by identifying and stating your interests with clarity. Include relevant specifics regarding your relationships with individuals or businesses that may present a conflict, much like in the CA Anthem Disclosure of Ownership and Control Interest Statement. Ensure your language is straightforward to avoid ambiguity. By providing this information, you help maintain transparency and uphold ethical standards.
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