1-844-477-8313
Provider Services
SunshineHealth.com
1301 International Pkwy.
Suite 400
Sunrise, FL 33323
Disclosure of Ownership And Control Interest Statement
The federal regulations set forth in 42 CFR 455.104, 455.105 and 455.106 require providers
who are entering into or renewing a provider agreement to disclose to the U.S. Department
of Health and Human Services, the state Medicaid agency, and to managed care
organizations that contract with the state Medicaid agency: 1) the identity of all owners with a
control interest of 5% or greater, 2) certain business transactions as described in 42 CFR
455.105 and 3) the identity of any excluded individual or entity with an ownership or control
interest in the provider, the provider group, or disclosing entity or who is an agent or
managing employee of the provider group or entity. If there are any changes to the
information disclosed on this form, an updated form should be completed and submitted to
Sunshine Health within 30 days of the change. Please attach a separate sheet if necessary
to provide complete information. This form is to be completed annually. Any substantial delay
in completing the form should be reported to the State survey agency.
Practice Information
Check one that most closely describes you:
Individual Group Practice Disclosing Entity
Name of Individual, Group Practice, or Entity:
DBA Name:
Address:
Federal Tax Identification Number:
1-844-477-8313
Provider Services
SunshineHealth.com
Section I
List the name, title, address, date of birth (DOB) and Social Security Number (SSN) for
each individual having an ownership or control interest in this provider entity of 5% or
greater.
List the name, Tax Identification Number (TIN), business address of each organization,
corporation, or entity having an ownership or control interest of 5% or greater. Please
attach a separate sheet if necessary. (42 CFR 455.104)
Name of
individual or entity
DOB Address SSN (if listing an
individual) TIN (if
listing an entity)
Section II
Are any of the individuals listed above related to each other? Yes No
If yes, list the individuals named above who are related to each other (spouse, sibling,
parent, child). (42 CFR 455.104)
Names Type of relation
1-844-477-8313
Provider Services
SunshineHealth.com
Section III
Are there any subcontractors that the Disclosing Entity has direct or indirect ownership of
5% or more? Yes No
If yes, list the name and address of each person with an ownership or controlling interest in
any subcontractor used in which the disclosing entity has direct or indirect ownership of 5%
or more. (42 CFR 455.104)
Name of
individual or entity
DOB Address SSN (if listing an
individual) TIN (if
listing an entity
Section IV
Has any person who has an ownership or control interest in the provider, or is an agent or
managing employee of the provider ever been convicted of a crime related to that person's
involvement in any program under Medicaid, Medicare, or Title XX Program?
Yes No (verify through OIG Website)
If yes, please list those persons below. (42 CFR 455.106)
Name/Title DOB Address SSN
1-844-477-8313
Provider Services
SunshineHealth.com
Section V
Business Transactions: Has the disclosing entity had any financial transaction with any
subcontractors totaling more that $25,000 or any significant business transactions with
any subcontractors? Yes No
If yes, list the ownership of any subcontractor with whom this provider has had business
transactions totaling more than $25,000 during the previous twelve month period; and
any significant business transactions between this provider and any wholly owned
supplier, or between the provider and any subcontractor, during the past 5-year period.
(42 CFR 455.105).
Attach a separate sheet if necessary.
Name
Supplier/Subcontractor
Address Transaction
Amount
Section VI
Have you identified your status (under Practice Information 1) as a Disclosing Entity?
Yes No
If yes, for Disclosing Entities, list each member of the Board of Directors or Governing
Board, including the name, date of birth (DOB), Address, Social Security Number (SSN),
and percent of interest
Name/Title DOB Address SSN % Interest
1-844-477-8313
Provider Services
SunshineHealth.com
I certify that the information provided herein, is true and accurate. Additions or revisions to
the information above will be submitted immediately upon revision. Additionally, I understand
that misleading, inaccurate, or incomplete data may result in a denial of participation.
Signature Title (or indicate if authorized Agent)
Name (please print) Date