Fillable Disclosure Ownership Form New (Arizona Health Care Cost Containment System)

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Disclosure Ownership Form New (Arizona Health Care Cost Containment System)

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1 of 3 Disclosure of Ownership/Control and Criminal Offenses 01/2015
DISCLOSURE OF OWNERSHIP/CONTROL
AND
CRIMINAL OFFENSES STATEMENTS
I. Provider Information See Instructions
(a) Name of Individual, Facility or Organization: _______________________________________________________________________
(b) Doing Business As (DBA) :_____________________________________________________________________________________________
(c) Federal Tax Identification Number (TIN) or Social Security Number (SSN): ______________________________________________
(d) National Provider Identifier # (NPI): ________________________________________
(e) Check the entity type that best describes the structure of the enrolling provider entity. Check only one box.
For-Profit Corporation
Non-Profit Corporation
Partnership
Government Owned
Sole Proprietorship
(f) Is this entity chain affiliated?
No
Yes
As required by 42 CFR Part 455, Subpart B, which sets forth State Plan requirements regarding Full Disclosure of Ownership and Control and Related Party
Transactions, the following information must be submitted to AHCCCS prior to registration and upon each renewal, revalidation, or within 35 days of any
change in ownership of the entity. In order to participate as an AHCCCS provider, this form must be completed completely and accurately.
AHCCCS may refuse to enter into or renew an agreement with a provider if the provider fails to disclose ownership and control interest information,
information related to business transactions and information on persons convicted of crimes, or if the provider did not fully and accurately make the disclosures
as required. If you are a government entity you do not need to complete items II (a), (b) and (e); however, you must submit information for item II (c).
II. Ownership and Control Interest Information (Reference - 42 CFR, Part 455, Subpart B and State Medicaid Director Letters 08-003 & 09-001)
(a) List the name, address, SSN and Date of Birth (DOB) for: 1) each officer and director (if incorporated); 2) each partner or member (if partnership or
limited liability corporation); 3) each individual who has direct or indirect ownership interest, separately or in combination, amounting to an ownership
interest of 5% or more of the enrolling provider; 4) each individual who has an ownership interest of 5% or more in any obligation secured by the
enrolling provider if that interest equals at least 5% of the value of the property or assets of the enrolling provider; and 5) each individual who is an officer,
director, partner or member, or who has a direct or indirect ownership interest, separately or in combination, amounting to an ownership interest of 5% or
more of any subcontractor in which the enrolling provider has a 5% or more interest.
Name
Address
DOB
SSN
Percentage
(b) List the name, address (including primary business address and all locations), and TIN of any organization, corporation, or other entity not disclosed in
Item II.(a) having any direct or indirect ownership, separately or in combination, amounting to an ownership interest of 5% or more, or any controlling
interest (e.g. officer, director, partner or member), in the enrolling provider or in any subcontractor in which the enrolling provider has a 5% or more
interest. Use attachment A if additional space is needed.
Name
Address
DOB
TIN
Percentage
(c) List below the name, address, date of birth, social security number and title of all agents and managing employees of the enrolling provider. Use
attachment A if additional space is needed.
Name
Address
DOB
SSN
Title
2 of 3 Disclosure of Ownership/Control and Criminal Offenses 01/2015
(d) List those persons named in Item II (a) and (b) who are related to each other as spouse, parent, child, or sibling.
Name
Address
DOB
SSN
Relationship
(e) List the name, address and TIN of any other disclosing entity in which a person with an ownership or control interest in the enrolling provider also has an
ownership or control interest of 5% or more in any other disclosing entity. For the purposes of this specific disclosure, “other disclosing entity” means any
entity required to make ownership and/or control disclosures pursuant to Titles V, XVIII, XIX, XX or XXI of the Social Security Act.
Name
Address
DOB
SSN
Relationship
III. Criminal Offenses (Reference - 42 CFR, Part 455, Subparts B and E, and SMLD 08-003 &09-001)
(a) List the name, SSN and DOB of each individual or entity disclosed in Item II who has been convicted of a criminal offense related to that person’s or
entity’s involvement in any program under Medicare, Medicaid or the Title XX services program since the inception of those programs.
Name
Address
SSN
DOB
(b) List the name, title, SSN and DOB of each individual disclosed in Item II who has been suspended or debarred from participation in any Medicare,
Medicaid or Title XX program at any time since the inception of those programs.
Name
Address
SSN
DOB
I affirm under penalty of law that the information I have provided for this form is true, accurate and complete to the best of my knowledge. If the provider is
using an Authorized Representative, the SSN and DOB are mandatory fields.
___________________________________________________________ ______________________ ___________________
Print Name of Disclosing Entity (Provider) or Authorized Representative SSN DOB
___________________________________________________________ _________________
Signature of Disclosing Entity (Provider) or Authorized Representative Date
Last Updated 01/2015
3 of 3 Disclosure of Ownership/Control and Criminal Offenses 01/2015
DISCLOSURE OF OWNERSHIP/CONTROL
AND
CRIMINAL OFFENSES STATEMENTS
ATTACHMENT A
Use the additional space provided below for Item II (a). Ownership and Control Interest Information
Name
Title
Address
SSN/TIN
Date of
Birth
Percentage
Use the additional space provided below for Item II (b). Ownership and Control Interest Information
Name
Address
TIN
Percentage
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Disclosure Ownership Form New (Arizona Health Care Cost Containment System)

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Completed 24 July 2020

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