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Pe Frd E (Commonwealth of Massachusetts)

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| page 1 |
PE-FRD-E (Rev. 09/19) FEDERALLY REQUIRED DISCLOSURES: ENTITIES
Disclosure Form for Entities
Commonwealth of Massachusetts | Executive Oce of Health and Human Services | mass.gov
As set forth in 42 CFR §§ 455.100-106, MassHealth providers, managed care entities (MCEs), scal agents, and other
disclosing entities seeking to provide MassHealth services (including Accountable Care Organizations (ACOs)), must
disclose information regarding business ownership and control, business transactions, and criminal convictions,
including submission of all relevant tax identication numbers (TINs), (e.g., social security number (SSN) or federal
employer identication number (FEIN)) in order to ensure proper administration of the MassHealth program.
As set forth in 42 CFR § 455.101, MCEs include the following (as dened in 42 CFR § 438.2).
• Health Insuring Organization (HIO)
• Prepaid Inpatient Health Plan (PIHP)
• Managed Care Organization (MCO)
• Primary Care Case Manager (PCCM)
• Prepaid Ambulatory Health Plan (PAHP)
e MassHealth agency may at its discretion disapprove a provider contract, and may terminate an existing contract, if
the provider fails to disclose any information in accordance with the provisions of 130 CMR 450.222, 130 CMR 450.223,
or 42 CFR §§ 455.100–106, 42 CFR § 455.436, 42 CFR § 1002, or as otherwise required by state or federal law (See 130
CMR 450.227).
NOTE: All sections of this form must be completed.
Unless otherwise instructed by MassHealth, all MCEs, scal agents, and other disclosing entities, including ACOs,
must use this form when disclosing such information to MassHealth upon:
• enrollment
• re-enrollment (following disenrollment from MassHealth)
• revalidation
• a change in managing employee(s)
• a change of ownership or control interest
• at the request of MassHealth
• any subsequent change(s) to any of the information stated on this form in accordance with
130 CMR 450.223(B)
CONTACT INFORMATION FOR INDIVIDUAL COMPLETING THIS FORM
Name
Tel.
Email
| page 2 |
PE-FRD-E (Rev. 09/19) FEDERALLY REQUIRED DISCLOSURES: ENTITIES
DEFINITIONS e following denitions provided here for reference are found at 42 CFR § 1001.2, 42 CFR §
455.101 and 130 CMR 450.221.
Agent: any person who has been delegated the authority to
obligate or act on behalf of a provider.
Disclosing Entity: a Medicaid provider (other than an
individual practitioner or group of practitioners), or a scal
agent.
Familial Relationship: parent, child, sibling, or spouse.
Fiscal Agent: a contractor that processes or pays vendor
claims on behalf of the Medicaid agency.
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 sta,
or common equipment).
Immediate Family Member: a person’s husband or wife;
natural or adoptive parent; child or sibling; step-parent,
stepchild, stepbrother or stepsister; father-, mother-,
daughter-, son-, brother- or sister-in-law; grandparent or
grandchild; or spouse of a grandparent or grandchild.
Indirect Ownership Interest: an ownership interest in an
entity that has an ownership interest in the disclosing entity.
is term includes an ownership interest in any entity that has
an indirect ownership interest in the disclosing entity.
Managed Care Entity (MCE): managed care organizations
(MCOs), PIHPs, PAHPs, PCCMs, and HIOs, as dened by 42
CFR §455.101.
Managing Employee: 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, or agency.
Member of Household: with respect to a person, any
individual with whom he or she is sharing a common abode as
part of a single family unit, including domestic employees and
others who live together as a family unit. A roomer or boarder
is not considered a member of household.
Other Disclosing Entity (ODE): any other Medicaid
disclosing entity and any entity that does not participate in
Medicaid, but is required to disclose certain ownership and
control information because of participation in any of the
programs established under Title V, XVIII, or XX of the Act.
is includes (a) any hospital, nursing facility, home health
agency, independent clinical laboratory, renal disease facility,
rural health clinic, or health maintenance organization that
participates in Medicare (Title XVIII); (b) any Medicare
intermediary or carrier; and (c) any entity (other than
an individual practitioner or group of practitioners) that
furnishes, or arranges for the furnishing of, health-related
services for which it claims payment under any plan or
program established under Title V or Title XX of the Act.
Ownership Interest: the possession of equity in the capital,
the stock, or the prots of the disclosing entity.
Person with Ownership or Control Interest: A person or
corporation that (a) has an ownership interest totaling ve
percent or more in a disclosing entity; (b) has an indirect
ownership interest equal to ve percent or more in a disclosing
entity; (c) has a combination of direct and indirect ownership
interests equal to ve percent or more in a disclosing entity;
(d) owns an interest of ve percent or more in any mortgage,
deed of trust, note, or other obligation secured by the
disclosing entity if that interest equals at least ve percent of
the value of the property or assets of the disclosing entity; (e)
is an ocer 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, or (g) owns directly or indirectly
an interest of ve percent or more in any real property leased
to a disclosing entity for use as a nursing facility, rest home, or
hospital.
An individual is deemed to own any benecial interest owned
directly or indirectly by or for his or her minor children or
spouse.
Signicant Business Transaction: any business transaction or
series of transactions that, during any one scal year, exceed
the lesser of $25,000 or ve percent (5%) of a provider’s total
operating expenses.
Subcontractor: (a) an individual, agency, or organization to
which a disclosing entity has contracted or delegated some
of its management functions or responsibilities of providing
medical care to its patients; or (b) an individual, agency, or
organization with which a scal agent has entered into a
contract, agreement, purchase order, or lease (or leases of real
property) to obtain space, supplies, equipment, or services
provided under the Medicaid agreement.
Supplier: an individual, agency, or organization from which a
provider purchases goods and services used in carrying out its
responsibilities under Medicaid (e.g., a commercial laundry, a
manufacturer of hospital beds, or a pharmaceutical rm).
Wholly Owned Supplier: a supplier whose total ownership
interest is held by a provider or by a person, persons, or other
entity with an ownership or control interest in a provider.
| page 3 |
PE-FRD-E (Rev. 09/19) FEDERALLY REQUIRED DISCLOSURES: ENTITIES
If additional space is needed, make a copy of this page and attach it to the signed form. NUMBER
_____
OF
_____
All entries must be submitted using this form. Please refer to all attached pages when completing and signing this form.
SECTION 1: Disclosing Entity Service Location / “Doing Business As” (SL/DBA) Name
Enter the SL/DBA name, address, and all other information requested below, applicable to this service location (SL)
where services will be provided or are currently provided to MassHealth members.
Disclosing Entity SL/DBA Name
Address (Street, Building or Suite)
City, State & Zip Code
NPI PID/SL (for existing MassHealth providers) FEIN
SECTION 2: Ownership or Control Interest in Disclosing Entity
List any individual or corporation with an ownership or control interest in the disclosing entity. Instructions for
determining ownership or control percentages can be found at 42 CFR § 455.102 and 130 CMR 450.221(B). Individuals
must provide their home address. Corporations must list, as applicable, their primary business address, all
business locations, corporate addresses, and P.O. Box addresses.
Which of the Ownership or Control Interest describes you (select one):
Ownership interest,
Control interest,
Both.
Name of Individual or Corporation Board of directors (if individual) Date of Birth (if individual) (MM/DD/YYYY)
Yes
No
Address (Home Address if Individual; Primary Business Address if Corporation) City, State & Zip Code (9 digit)
SSN (if individual) FEIN (if corporation) % of Ownership NPI (
check the box if None)
For Individuals Only: If the individual listed above is related as a parent, child, sibling, or spouse to another person with an ownership or control interest in the
disclosing entity, complete the following: Name of other person with ownership or control interest and relationship to the individual listed above (check one)
1.
parent
child
sibling
spouse
2.
parent
child
sibling
spouse
3.
parent
child
sibling
spouse
For Corporations Only: Use the space below to report the address of all other business locations, corporate addresses, and P.O. box addresses.
1.
2.
3.
Which of the Ownership or Control Interest describes you (select one):
Ownership interest,
Control interest,
Both.
Name of Individual or Corporation Board of directors (if individual) Date of Birth (if individual) (MM/DD/YYYY)
Yes
No
Address (Home Address if Individual; Primary Business Address if Corporation) City, State & Zip Code (9 digit)
SSN (if individual)
FEIN (if corporation) % of Ownership NPI (
check the box if None)
For Individuals Only: If the individual listed above is related as a parent, child, sibling, or spouse to another person with an ownership or control interest in the
disclosing entity, complete the following: Name of other person with ownership or control interest and relationship to the individual listed above (check one)
1.
parent
child
sibling
spouse
2.
parent
child
sibling
spouse
3.
parent
child
sibling
spouse
For Corporations Only: Use the space below to report the address of all other business locations, corporate addresses, and P.O. box addresses.
1.
2.
3.
| page 4 |
PE-FRD-E (Rev. 09/19) FEDERALLY REQUIRED DISCLOSURES: ENTITIES
If additional space is needed, make a copy of this page and attach it to the signed form. NUMBER
_____
OF
_____
All entries must be submitted using this form. Please refer to all attached pages when completing and signing this form.
SECTION 3: Ownership in Other Disclosing Entities (ODE)
Complete if any individual or corporation identied in Section 2 has an ownership or control interest in other disclosing
entities.
NONE (if NONE continue to Section 4)
Name (from Section 2) Title ODE Name
ODE Address City, State, & Zip Code (9 digit)
Name (from Section 2) Title ODE Name
ODE Address City, State, & Zip Code (9 digit)
SECTION 4: Ownership in Subcontractors
List any individual or corporation with an ownership or control interest in any subcontractor in which the disclosing
entity has an ownership or control interest. If none, check ‘None’ below.
NONE (if NONE continue to Section 5)
Name of individual or corporation
TIN of individual or corporation (TIN)
Owner’s Address City, State, & Zip Code (9 digit)
Subcontractor Name Subcontractor Tax Identification Number (TIN)
Subcontractor Primary/Home Address City, State, & Zip Code (9 digit)
Name of individual or corporation TIN of individual or corporation (TIN)
Owner’s Address City, State, & Zip Code (9 digit)
Subcontractor Name Subcontractor Tax Identification Number (TIN)
Subcontractor Primary/Home Address City, State, & Zip Code (9 digit)
SECTION 5: Familial Relationship in Subcontractors
Complete if anyone identied in Section 2 is related to a person identied in Section 4 as a parent, child, sibling, or
spouse. If none, check ‘None’ below.
NONE (if NONE continue to Section 6)
Name of individual with ownership or control interest identified in Section 2
Name of individual with ownership or control interest identified in Section 4 and familial relationship to individual identified in Section 2
Name of individual with ownership or control interest identified in Section 2
Name of individual with ownership or control interest identified in Section 4 and familial relationship to individual identified in Section 2
| page 5 |
PE-FRD-E (Rev. 09/19) FEDERALLY REQUIRED DISCLOSURES: ENTITIES
If additional space is needed, make a copy of this page and attach it to the signed form. NUMBER
_____
OF
_____
All entries must be submitted using this form. Please refer to all attached pages when completing and signing this form.
SECTION 6: Agents and Managing Employees
Completion of all elds is required by 42 CFR § 455.104. Make copies if additional space is needed. All entries must be
submitted using this form.
Agent
Managing employee
Both
Name Title
Home Address City, State, & Zip Code (9 digit)
SSN
Date of Birth (MM/DD/YYYY)
Agent
Managing employee
Both
Name Title
Home Address City, State, & Zip Code (9 digit)
SSN
Date of Birth (MM/DD/YYYY)
Agent
Managing employee
Both
Name Title
Home Address City, State, & Zip Code (9 digit)
SSN
Date of Birth (MM/DD/YYYY)
Agent
Managing employee
Both
Name Title
Home Address City, State, & Zip Code (9 digit)
SSN
Date of Birth (MM/DD/YYYY)
Agent
Managing employee
Both
Name Title
Home Address City, State, & Zip Code (9 digit)
SSN
Date of Birth (MM/DD/YYYY)
Agent
Managing employee
Both
Name Title
Home Address City, State, & Zip Code (9 digit)
SSN
Date of Birth (MM/DD/YYYY)
| page 6 |
PE-FRD-E (Rev. 09/19) FEDERALLY REQUIRED DISCLOSURES: ENTITIES
SECTION 7: Disclosures of Criminal Convictions and Relationships to Excluded Individuals
and Entities
For additional information, see 42 CFR §§ 455.106 and 455.436, 42 CFR §§ 1001.1001 and 1002.3, and 130 CMR
450.212.
Respond to the following questions on behalf of:
1. the disclosing entity
2. all individuals and corporations identied in Sections 2 and 6 of this form
3. any person who formerly held an ownership or control interest in the entity but no longer holds an ownership or
control interest because of a transfer of the interest to an immediate family member or a member of the person’s
household in anticipation of or following a conviction, imposition of a civil money penalty or assessment under
Section 1128A of the Social Security Act, or imposition of an exclusion.
NOTE: All questions must be answered. If “yes” is answered to any of the questions in Section 7 below, a detailed
explanation is required in Section 8 of this form, including the name Social Security Number (SSN)/Tax Identication
Number (TIN) and address of the individual/entity; nature, date, and forum of the action; and any case or record
number.
1. Have any of the individuals/entities ever been convicted of a criminal offense related to any program under Medicare, Medicaid, or Title XX services?
Yes
No
2. Have any of the individuals/entities been convicted of a criminal offense as described in sections 1128(a) and 1128(b) (1), (2), or (3) of the Social Security Act?
Yes
No
3. Have any of the individuals/entities been excluded from participation in any federal or state health program (including, but not limited to, Medicare or Medicaid)?
Yes
No
4. Have any of the individuals/entities had civil money penalties or assessments imposed under section 1128A of the Social Security Act?
Yes
No
5. Is there currently pending any proceeding(s) that could result in a conviction, sanction, or other action reportable in questions 1 – 4, above?
Yes
No
NOTE: All questions must be answered. If “Yes” is answered to any of the questions in Section 7 above, a detailed
explanation is required in Section 8 of this form, including the name Social Security Number/Tax Identication Number
(SSN/TIN) and address of the individual/entity; nature, date, and forum of the action; and any case or record number.
| page 7 |
PE-FRD-E (Rev. 09/19) FEDERALLY REQUIRED DISCLOSURES: ENTITIES
If additional space is needed, make a copy of this page and attach it to the signed form. NUMBER
_____
OF
_____
All entries must be submitted using this form. Please refer to all attached pages when completing and signing this form.
SECTION 8: Additional Explanation
If “Yes” is answered to any of the questions in Section 7, a detailed explanation is required below, including the name,
Social Security Number/Tax Identication Number (SSN/TIN) and address of the individual/ entity, nature, date, and
forum of the action, and any case or record number.
Attach additional pages if necessary.
| page 8 |
PE-FRD-E (Rev. 09/19) FEDERALLY REQUIRED DISCLOSURES: ENTITIES
SECTION 9: Attestation, Signature, and Date
All disclosing entities must complete this section.
I certify that the information on this form, and any attached statement that I have provided, has been reviewed and
signed by me, and is true, accurate, and complete, to the best of my knowledge.
I understand that I sign under the pains and penalties of perjury, and may be subject to civil penalties or criminal
prosecution for any falsication, omission, or concealment of any material fact contained herein.
I agree to abide by all applicable federal and state laws and regulations, as well as the rules and regulations of particular
to the type of program covered by this enrollment application.
Note: Signature or date stamps, electronically generated signatures or dates, or the signature of anyone other than
the disclosing entity or person legally authorized to sign on behalf of the entity are not acceptable.
In accordance with 130 CMR 450.223(B), I agree to notify the MassHealth agency in writing within 14 days of any
change to any of the information submitted upon enrollment.
In accordance with 42 CFR § 455.105, I agree to disclose full and complete information regarding the following business
transactions within 35 days following a request of the MassHealth agency or the Secretary of Health and Human
Services:
1. Information about the ownership of any subcontractor with whom the provider, MCE, or disclosing entity has
had business transactions totaling more than $25,000 during the 12-month period ending on the date of the
request; and
2. Any signicant business transactions between the provider and any wholly owned supplier or between the
provider and any subcontractor during the 5-year period ending on the date of the request.
Signature:
Printed Name
Title
Date (
MM/DD/YYYY)
Return your completed form to providersupport@mahealth.net or mail to the following:
MassHealth Customer Service Center
Attn: Provider Enrollment and Credentialing
PO Box 121205
Boston, MA 02112-1205
If you have questions about or need assistance with the completion of this form, please email the MassHealth
Customer Service Center at providersupport@mahealth.net or call (800) 841-2900.
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Pe Frd E (Commonwealth of Massachusetts)

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Completed 19 July 2020

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