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Get KS Disclosure of Ownership and Control Interest Statement 2014

Nswered by fiscal agents and by all providers EXCEPT individual practitioners. If more space is needed, provide the information on a separate piece of paper and attach to this document. 1. Provide the following information for each person (individual or corporation) with an ownership or control interest in the provider/fiscal agent/managed care entity or in any subcontractor in which the provider/fiscal agent has direct or indirect ownership of five percent or more. Name # Address Date of Birt.

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