1of 1 Disclosure of Criminal Offenses Last updated 01/2015
Instructions for Criminal Offenses Disclosures
These instructions are for use with the Disclosure of Criminal Offenses form. This form may be used solely by individual practitioners and not by
any business organization. Definitions of the terms used in this form are included at the end of this document. Please answer all questions as of the
current date.
Completion and submission of this form is a federal and state requirement, and a condition of participation in the Medicaid program. Failure to
submit complete and accurate information may cause AHCCCS to refuse to enter into an agreement or contract with the individual practitioner, or
to terminate existing agreements. These disclosures are required under 42 CFR Part 455, Subparts B and E.
I. Enrolling Provider Information
Complete this section with information about yourself as the provider entity. Specify the provider’s name, (legal name reported
to the IRS), other names used, the Federal Tax ID associated with the provider (FEIN or SSN), the National Provider Identifier (NPI),and the
Doing Business As (DBA) name, as applicable.
II. Disclosures
The disclosures of agents and managing employees, along with the Enrolling Provider’s information, are necessary for AHCCCS to complete its
screening obligations under 42 CFR Part 455, Subpart E. AHCCCS also requires disclosures regarding the Enrolling Provider’s ownership or
control interests in other disclosing entities.
III. Criminal Offenses
This section is about yourself as individual provider and any person who is associated with your practice or who is associated with you for
purposes of the provision of services under the terms of the provider agreement with AHCCCS.
Definitions
Agent means a person who has been delegated the authority to obligate or act on behalf of the entity.
Control interest is defined as the operation direction or management of disclosing entity which may be maintained by any or all of the following
devices: the ability or authority, expressed or reserved, to amend or change the corporate identity (i.e., joint venture agreement, unincorporated
business status) of the disclosing entity; the ability or authority to nominate or name members of the Board of Director or Trustees of the
disclosing entity; the ability or authority, expressed or reserved, to amend or change the bylaws, constitution, or other operating or management
direction of the disclosing entity; the right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution
of that entity; the ability or authority, expressed or reserved, to control the sale of any or all or the assets, to encumber such assets by way of
mortgage or other indebtedness, to dissolve the entity or to arrange for the sale or transfer of the disclosing entity to new ownership or control.
Disclosing Entity: A Medicaid provider other than an individual practitioner or group of practitioners.
Direct ownership/control interest is defined as the possession of stock, equity in capital or any interest in the profits in the profits of the
disclosing entity.
Group of Practitioners: Two or more health care practitioners who practice their profession at a common location (whether or not they share
common facilities, common supporting staff, or common equipment.
Indirect ownership is defined as ownership interest in an entity that had direct or indirect ownership interest in the disclosing entity. The amount
of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at
each level. An indirect ownership interest must be reported if it equates to an ownership interest of 5 percent or more in the disclosing entity.
Example: If A owns 10 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing entity. A’s interest equates to an 8
percent indirect ownership and must be reported.
Managing employee means a general manager, business manager, administrator, director or other individual who exercises operational or
managerial control over, or who directly or indirectly conducts the day to day operation of the disclosing entity.
Other Disclosing Entity: any entity required to make ownership and/or control disclosures pursuant to Titles V, XVIII, XIX, XX or XXI of the
Social Security Act.
Person with an ownership or control interest is a person or corporation that:
(a) Has an ownership interest totaling 5 percent or more in a disclosing entity.
(b) Has an indirect ownership interest equal to 5 percent or more in a disclosing entity.
(c) Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity.
(d) Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest
equals at least 5 percent of the value of the property or assets of the disclosing entity.
(e) Is an officer or director of a disclosing entity that is organized as a corporation.
(f) Is a partner in a disclosing entity that is organized as a partnership.
