Fillable DS 1891 Application/ Vendor Disclosure Statement

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DS 1891 Application/ Vendor Disclosure Statement

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State of California–Health and Human Services Agency Department of Developmental Services
APPLICANT/VENDOR DISCLOSURE STATEMENT
DS 1891 (7/2011)
Page 1
GENERAL INSTRUCTIONS
Every applicant or vendor must complete and submit a current Applicant/Vendor Disclosure Statement, DS 1891 (disclosure
statement) as part of a complete application packet for vendorization or upon request of the vendoring regional center. The
following instructions are designed to clarify certain questions on the form. Instructions are listed in order of question for easy
reference. See 42 CFR 455.101 for additional definitions.
Overall Authority: Code of Federal Regulations (CFR), Title 42, Part 455; California Code of Regulations, Title 17, Section 54311. Welfare and
Institutions Code, Section 4648.12.
Important:
• IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL
INFORMATION BE CURRENT.
• Failure to disclose complete and accurate information will result in a denial of enrollment and/or may be cause for
termination of vendorization.
• Read ALL instructions when completing the disclosure statement.
• Type or print clearly in ink.
• If applicant or vendor must make corrections, please line through, date, and initial in ink. Do not use correction fluid.
• Answer all questions as of the current date.
• If additional space is needed, attach a sheet referencing the part and question being completed.
• Return this completed statement with the complete application package to the regional center to which you are applying.
Part 1: Identifying Information
A. Specify name of the applicant or vendor, agency, facility or organization, vendor number and service code, business
address, and telephone number of applicant or vendor submitting the vendor application.
B. Specify in what capacity the applicant or vendor is doing business. For example: The name of the corporation under
which they are doing business. This name must match the license name, if applicable.
C. List the Medi-Cal provider number, if any, of the applicant or vendor.
D. List the Social Security Number and/or the Federal Employer Identification Number (EIN) of the applicant or vendor, if
any. Enter Vendor’s nine-digit EIN assigned by the IRS in the following format: XX-XXXXXXX.
An EIN is used to identify the accounts of employers and certain others who have no employees.
For more information about an EIN, please check http://www.irs.gov
for “Employer Identification Numbers” or “EIN”.
Whenever this Disclosure Statement requests an EIN about an individual or entity, it has the same meaning.
E. Check the entity type that best describes the structure of your organization.
Part 2: Ownership and Control Interests. Use the following definitions to identify the individuals you should enter in
parts A, B and C of this section. See 42 CFR 455.101 for additional definitions.
“Indirect Ownership Interest” means an ownership interest in an entity that has an ownership interest in the applicant or
vendor. This term includes an ownership interest in any entity that has an indirect ownership interest in the applicant or
vendor;
“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 an
institution, organization, agency or business entity;
“Ownership Interest” means the possession of equity in the capital, the stock, or the profits of the applicant or vendor.
“Person with an Ownership or Control Interest” means a person or corporation that:
A) Has an ownership interest totaling 5 percent or more in an applicant or vendor;
B) Has an indirect ownership interest equal to 5 percent or more of an applicant or vendor;
C) Has a combination of direct or indirect ownership interests equal to 5 percent or more in an applicant or
vendor;
D) Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the
applicant or vendor if that interest equals at least 5 percent of the value of the property or assets of the applicant or
vendor;
E) Is an officer or director of an applicant or vendor that is organized as a corporation; or
F) Is a partner in an applicant or vendor that is organized as a partnership.
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State of California–Health and Human Services Agency Department of Developmental Services
APPLICANT/VENDOR DISCLOSURE STATEMENT
DS 1891 (7/2011)
Page 2
“Significant Business Transaction” means any business transaction or series of transactions that, during any one fiscal
year, exceed the lesser of $25,000 and 5 percent of an applicant or vendor’s total operating expenses.
“Subcontractor” means an individual, agency, or organization to which an applicant or vendor has contracted or
delegated some of the management functions or responsibilities of providing services.
“Wholly Owned Supplier” means a supplier whose total ownership interest is held by an applicant or vendor or by a
person, persons, or other entity with an ownership or control interest in an applicant or vendor.
Part 3: Excluded Individuals or Entities. (See page
3, part 3. M
ust be disclosed if applicable.)
“Excluded Individuals or Entities” means those individuals and entities that have been placed on either the U.S. Department
of Health and Human Services Office of Inspectors’ General (OIG) List of Excluded Individuals/Entities or the Department of
Health Care Services (DHCS) Medi-Cal Suspended and Ineligible Provider List of persons, or individuals and entities that
have been convicted of a criminal offense related to involvement in any program under Medicare, Medicaid or the Title XX
services program, or those individuals and entities that meet the criteria included in Section 54311(a)(6).
PLEASE FILL OUT
1. Applicant/Vendor Information
A. Name of applicant or vendor, entity, agency, facility, or organization as reported to IRS:
Vendor Number and Service Code:
Business Address:
Telephone number (with area code):
B. DBA Name registered with California Secretary of State, if any:
C. Medi-Cal Provider Number, if any:
D. Social Security Number and/or Federal Employer Identification Number (EIN), if any:
E. Check the entity type that best describes the structure of the applicant or vendor individual, business entity, agency, facility
or organization: Check only one
box:
□ Sole Proprietor (Unincorporated)
□ General Partnership □ Limited Partnership □ Limited Liability Partnership
□ Limited Liability Company: State of formation: ____________________________
□ Governmental
□ Corporation: Corporate number: State incorporated: _____________
□ Nonprofit – Check One:
□ Unincorporated Association
□ Corporation
□ Religious/Charitable
□ Other (specify): ____________________________________________
State of California–Health and Human Services Agency Department of Developmental Services
APPLICANT/VENDOR DISCLOSURE STATEMENT
DS 1891 (7/2011)
Page 3
2. Ownership, indirect ownership, and managing employee interests
A. List the name(s), title(s) and address(es) of individuals for organizations having direct or indirect ownership interests,
and/or managing employees in the applicant/vendor (see instructions for definitions). Also list all members of a group
practice. Attach additional pages as necessary to list all officers, owners, management and ownership individuals and
entities.
Name Title Address
B. List those persons named in A or B above, that are related to each other as spouse, parent, child, or sibling.
Name Relationship Address
C. List the name, address, vendor number and service code, and Medi-Cal provider number of any other applicant or vendor
in which a person with an ownership or controlling interest in the applicant or vendor also has an ownership or control interest
of at least 5 percent or more. For example: Are any owners of the applicant or vendor also owners of Medicare or Medicaid
facilities? (Example: sole proprietor, partnership or members of Board of Directors.)
Name Address
Vendor Number
and Service Code
Medi-Cal
Provider
Number
3. Excluded Individuals or Entities
List the name, title, and address of any person or entity with an ownership or control interest, any agent, director, officer, or
managing employee of the applicant or vendor who is an excluded individual or entity, as defined on page 2.
Name Title Address
4. Subcontractor
A. List the name and address of each person or entity with an ownership or control interest in any subcontractor in which
the applicant or vendor has direct or indirect ownership of 5 percent or more.
Name Title Address Percentage
B. List the name and address of each subcontractor or wholly owned supplier in which the applicant or vendor has had
any significant business transactions within 5 years of the application or request.
Name Title Address
State of California–Health and Human Services Agency Department of Developmental Services
APPLICANT/VENDOR DISCLOSURE STATEMENT
DS 1891 (7/2011)
Page 4
APPLICANT/VENDOR SIGNATURE
Knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to
become vendored, or if the service provider already is vendored, a termination of its vendorization.
By signing this disclosure statement, you hereby certify and swear under penalty of perjury that (a) you have knowledge
concerning the information above, and (b) the information above is true and accurate. You agree to inform the vendoring
Regional Center, in writing, within 30 days of any changes or if additional information becomes available.
Name of Authorized Representative (Type or Print) Title
Signature Date
Recordkeeping and Access to Records
Subject to the provisions of Title 17, California Code of Regulations, Section 54311 and Code of Federal Regulations,
Title 42, Part 455.105, an applicant or vendored provider agrees to provide access for the review of any and all ownership
disclosure information and/or documentation upon written request by the vendoring regional center, the Department of
Developmental Services, the State Medicaid Agency, Department of Health Care Services, any State survey team, the
Secretary of the United States Department of Health and Human Services, or any duly authorized representatives of the
above named entities.
Privacy Statement
All information requested on the application and the disclosure statement is mandatory with the exception of the social
security number for any person other than the person or entity for whom an IRS Form 1099 must be provided by the
Department of Developmental Services pursuant to 26 USC 6041. This information is required by the authority of Welfare
and Institutions Code, Section 4648.12 and Title 17, California Code of Regulations, Section 54311. The consequences of
not supplying the mandatory information requested are denial of vendorization as a regional center vendor or termination of
vendorization. Any information may also be provided to the State Controller’s Office, the California Department of Justice,
the Department of Consumer Affairs, other state or local agencies as appropriate, fiscal intermediaries, managed care plans,
the Federal Bureau of Investigation, the Internal Revenue Service, Medicare Fiscal Intermediaries, Centers for Medicare and
Medicaid Services, Office of the Inspector General, Medicaid, or licensing programs in other states.
Title 17 California Code of Regulations, Section 54311(a)(6)
(Criteria for Excluded Individuals or Entities to be disclosed on Page 3, Part 3)
The name, title and address of any person(s) who, as applicant or vendor, or who has ownership or control interest in
the applicant or vendor, or is an agent, director, members of the board of directors, officer, or managing employee of
the applicant or vendor, has within the previous ten years:
(A) Been convicted of any felony or misdemeanor involving fraud or abuse in any government program, or
related to neglect or abuse of an elder or dependent adult or child, or in any connection with the interference
with, or obstruction of, any investigation into health care related fraud or abuse; or
(B) Been found liable any civil proceeding for fraud or abuse involving any government program; or
(C) Entered into a settlement in lieu of conviction involving fraud or abuse in any government program.
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DS 1891 Application Vendor Disclosure Statement

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Completed 29 July 2020

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