Get Ks Disclosure Of Ownership And Control Interest Statement 2014

The KS Disclosure of Ownership and Control Interest Statement is an essential document for providers to disclose their ownership and control interests. This guide provides a clear and supportive walkthrough for completing the form online, ensuring users understand each section.

Follow the steps to fill out your statement online carefully.

1. Click the ‘Get Form’ button to access the KS Disclosure of Ownership and Control Interest Statement and open it in your preferred document viewer.
2. Begin by entering the name of your entity or individual in the designated field at the top of the form.
3. Provide your address, including city, state, and zip code. Ensure that the details are accurate as they are essential for identification.
4. Insert your EIN or SSN number in the respective field. If you are an individual, also include your date of birth.
5. Next, enter your NPI in the given field. This is required for identification within the Medicaid system.
6. Questions 1 through 3 must be answered by fiscal agents and all providers except individual practitioners. If additional space is needed, attach a separate piece of paper.
7. For question 1, list everyone with an ownership or control interest over 5% in the provider or fiscal agent, including both individuals and corporations. Fill in their names, addresses, dates of birth (if applicable), and social security numbers accordingly.
8. Continue with section 1A where you will identify corporations listed in question 1 by assigning them labels 1A, 1B, etc. Provide their tax identification numbers and primary business addresses.
9. Question 2 asks if any individuals listed in question 1 are related to each other, such as by family ties. Indicate relationships clearly.
10. Question 3 requires you to disclose if any person listed has ownership or control interests in other Medicaid providers or entities that must disclose similar information. Provide names, addresses, and tax ID numbers as necessary.
11. For group providers, answer question 4 regarding relationships between group physicians and those with ownership interests.
12. Respond to questions 5 through 15, which gather information about criminal convictions, business transactions, and any adverse legal actions. Ensure you provide comprehensive details as prompted.
13. Once you have filled out all required sections, review your responses for accuracy.
14. Finally, you can save your changes, download a copy of the completed document, print it, or share it as required.

Complete your KS Disclosure of Ownership and Control Interest Statement online today to maintain compliance and ensure a smooth application process.