
Get Ma Disclosure Of Ownership And Control Interest Statement
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How to fill out the MA Disclosure of Ownership and Control Interest Statement online
Completing the MA Disclosure of Ownership and Control Interest Statement is a critical step in meeting regulatory requirements for healthcare providers. This guide provides clear, step-by-step instructions to help you accurately fill out the form online.
Follow the steps to fill out the form accurately and efficiently.
- Click ‘Get Form’ button to obtain the form and open it in the online editor.
- Begin by entering your identifying information, including the name of your entity, doing business as (DBA) name, street address, provider number, telephone number, city, county, state, and zip code.
- Answer the questions in Item II by selecting 'Yes' or 'No.' If you answer 'Yes' to any question, provide the necessary details in the Remarks section on page 2, identifying the related item number.
- In Item III, list names and addresses of all individuals or organizations with a direct or indirect ownership interest or controlling interest of 5 percent or more in your entity.
- In Items IV to VII, indicate any changes in provider status. For each item, specify the relevant details if applicable and provide dates of changes as necessary.
- If a management company operates your facility, complete Item V with the name of the management firm and its employer identification number (EIN) if applicable.
- Once all fields and questions are addressed, review your information carefully for accuracy.
- Save changes, download, print, or share the completed form as required for your records and to send to the relevant state agency.
Complete your MA Disclosure of Ownership and Control Interest Statement online today to ensure compliance.
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A disclosure statement is a formal document that communicates important information about an entity's ownership and control structures. It helps stakeholders understand who manages the organization and their relationships. The MA Disclosure of Ownership and Control Interest Statement serves this purpose by ensuring that all ownership interests are rightly disclosed.
Fill MA Disclosure of Ownership and Control Interest Statement
OWNERSHIP AND CONTROL INTEREST STATEMENT (1513)​​ A full and accurate disclosure of ownership and financial interest is required. List any individual or corporation with an ownership or control interest in the disclosing entity. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. Ownership interest means an interest in: ▫ the capital, the stock, or the profits of the applicant; or. The instructions below provide guidance on how to complete the Disclosure of Ownership and Control Interest. Statement. You must submit the Provider Disclosure of Ownership and Control Interest Statement form with your initial participation agreement. You must submit the Provider Disclosure of Ownership and Control Interest Statement form with your initial participation agreement. III. (a) List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. Has an ownership interest totaling 5 percent or more in a disclosing entity. b. The information required includes, but it is not limited to, name, address, date of birth, social security number (SSN) and tax identification (TIN).
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