Disclosure of Ownership & Control Interest Form Requirements

 
LIBERTY Dental Plan is required by Medicaid to have a current Disclosure of Ownership and Control Interest Form for Providers for every business participating in our Medicaid networks. 
 
LIBERTY has posted additional documents below to assist businesses in the completion of this form.

  
  • A fillable PDF version of the Disclosure of Ownership and Control Interest Form for Providers can be completed and signed electronically using Adobe Sign, Docusign or similar software. The document will then be ready to upload to LIBERTY Dental Plan
  • How to Complete Disclosure of Ownership and Conflict of Interest Forms:
    • Appendix A- Disclosure or Ownership defines Disclosing Entities, Other Disclosing Entities, and provides requirements on what and who are required to disclose direct and indirect ownership.
    • DOO Example- All Boxes Must Be Completed even if the response is N/A.
    • Section 1 to Section 7:  All questions MUST be answered on page 1.  
    •  Table 1:  Disclosure Regarding Managing Employees must be populated and cannot be blank and cannot indicate N/A.
    • Table 2:  Criminal Offense Disclosure must be completed.  If it’s not applicable enter N/A.
    • Table 3:  Person(s) with Ownership or Control Interest Disclosure must be populated and cannot be blank and cannot indicate N/A.
    • Table 4:  Direct or Indirect Ownership of 5% or more in a Subcontractor Disclosure must be populated and cannot be blank and cannot indicate N/A.  An entity or individual with 5% or more director or indirect ownership must be disclosed.
    • Table 5:  Other Disclosing Entity Disclosure must be populated if it is applicable.  The definition of Other Disclosing Entity is in Appendix A- Disclosure of Ownership.
    • Table 6:  Business Transactions Disclosure (Subcontractor) must be populated if it is applicable.  The definition of Subcontractor is in Appendix A- Disclosure of Ownership.
    • Table 7:  Significant Business Transactions Disclosure must be populated if it is applicable.  The definition of Significant Business Transaction is in Appendix A- Disclosure of Ownership.
    • Section B- Attestation:  All sections must completed.  The form must be signed and dated.
 
  • Read Appendix A- Disclosure of Ownership for helpful information on the federal code or regulation governing Disclosure of Ownership Requirements.
  • Any Disclosure of Ownership and Control Interest Form which is INCOMPLETE cannot be accepted.
  • LIBERTY uses the State Department of Corporations to ensure all entities are active corporations.
  • LIBERTY will validate if an entity is an active corporation in another state.

Providers

Disclosure of Ownership & Control Interest Form Requirements

 
LIBERTY Dental Plan is required by Medicaid to have a current Disclosure of Ownership and Control Interest Form for Providers for every business participating in our Medicaid networks. 
 
LIBERTY has posted additional documents below to assist businesses in the completion of this form.

  
  • A fillable PDF version of the Disclosure of Ownership and Control Interest Form for Providers can be completed and signed electronically using Adobe Sign, Docusign or similar software. The document will then be ready to upload to LIBERTY Dental Plan
  • How to Complete Disclosure of Ownership and Conflict of Interest Forms:
    • Appendix A- Disclosure or Ownership defines Disclosing Entities, Other Disclosing Entities, and provides requirements on what and who are required to disclose direct and indirect ownership.
    • DOO Example- All Boxes Must Be Completed even if the response is N/A.
    • Section 1 to Section 7:  All questions MUST be answered on page 1.  
    •  Table 1:  Disclosure Regarding Managing Employees must be populated and cannot be blank and cannot indicate N/A.
    • Table 2:  Criminal Offense Disclosure must be completed.  If it’s not applicable enter N/A.
    • Table 3:  Person(s) with Ownership or Control Interest Disclosure must be populated and cannot be blank and cannot indicate N/A.
    • Table 4:  Direct or Indirect Ownership of 5% or more in a Subcontractor Disclosure must be populated and cannot be blank and cannot indicate N/A.  An entity or individual with 5% or more director or indirect ownership must be disclosed.
    • Table 5:  Other Disclosing Entity Disclosure must be populated if it is applicable.  The definition of Other Disclosing Entity is in Appendix A- Disclosure of Ownership.
    • Table 6:  Business Transactions Disclosure (Subcontractor) must be populated if it is applicable.  The definition of Subcontractor is in Appendix A- Disclosure of Ownership.
    • Table 7:  Significant Business Transactions Disclosure must be populated if it is applicable.  The definition of Significant Business Transaction is in Appendix A- Disclosure of Ownership.
    • Section B- Attestation:  All sections must completed.  The form must be signed and dated.
 
  • Read Appendix A- Disclosure of Ownership for helpful information on the federal code or regulation governing Disclosure of Ownership Requirements.
  • Any Disclosure of Ownership and Control Interest Form which is INCOMPLETE cannot be accepted.
  • LIBERTY uses the State Department of Corporations to ensure all entities are active corporations.
  • LIBERTY will validate if an entity is an active corporation in another state.