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:
