Disclosure of Ownership and Control Interest Form
for Providers and Vendors

Complete Sections A and B.
For complete Instructions and Definitions at the end.

Section A: Please answer all of the following:
If you answered Yes to any questions, complete the Table(s) indicated, then sign the Attestation (Section B) on page 4
If you answered No to all questions, complete and sign the Attestation (Section B) on page 4
Section 1. Disclosure Regarding Managing Employees
Does the provider/vendor have any Managing Employees (CEO, Administrator, Director, COO, CFO, etc.)
Complete Table 1
Section 2. Criminal Offense Disclosure
Has the provider/vendor, or any Person (individual or entity) Who Has Ownership or Controlling Interest in the provider/vendor, or who is an Agent or Managing Employee of the provider/vendor, ever been convicted of a criminal offense related to that person's involvement in any program established under Titles XVIII (Medicare), XIX (Medicaid), XXI (SCHIP), or Title XX (Social Services Block Grants) since the inception of those programs? Verify exclusion through the applicable federal and state specific exclusion databases.
Complete Table 2
Section 3. Person(s) with Ownership or Control Interest Disclosure
Are there any Persons (individual or entity) With an Ownership or Control Interest in the provider/vendor?
Complete Table 3
Section 4. Direct or Indirect Ownership of 5% or More in a Subcontractor Disclosure
Does the provider/vendor have an Ownership Interest or Indirect Ownership Interest of 5% or more in any Subcontractor?
Complete Table 4, 4A
Section 5. Other Disclosing Entity Disclosure
Does the provider/vendor or any one named in Table 3 have an Ownership or Control Interest in any other Medicaid provider?
Complete Table 5
5A. Does the provider/vendor or any one named in Table 3 have an Ownership or Control Interest in any other disclosing 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 (Maternal and Child Health Services Block Grant), XVIII (Medicare), XX (Block Grants to States for Social Services), or Title XXI (State Children’s Health Insurance Program) of the Social Security Act?
Complete Table 5
Section 6. Business Transactions Disclosure
Business Transactions - Subcontractors: Has the provider/vendor had any business transactions with a Subcontractor totaling more than $25,000 in the previous twelve (12) month period (12- month period ending as of the date on this request)?
Complete Table 6
Section 7. Significant Business Transaction Disclosure
Significant Business Transactions: Has the provider/vendor had any Significant Business Transactions with a Wholly Owned Supplier or Subcontractor during the previous 5-year period (5- year period ending as of the date on this request)?
Complete Table 7
Table 1
Disclosure Regarding Managing Employees
Provide the following details for any Managing Employee of the provider/vendor (See the definition of Managing Employee)
Name
(First, Middle, Last)		 SSN Birthdate Complete Address
(Street, City, State, Zip)
NPI
(If applicable) 		Position
Table 2
Criminal Offense Disclosure
Provide the following details and a description of offense(s). Use additional pages if necessary.
Name
(First, Middle, Last)		 SSN/TIN Birthdate Description
Table 3
Person(s) with Ownership or Control Interest Disclosure
Provide the following details and include the title (for example, CEO, CFO, COO, owner, board member etc). Please attach additional pages if necessary. * For corporations/entities that have an ownership or control interest in the Disclosing Provider, please separately list its primary business address, every business location and post office box address. (See the definition of a person with an ownership or control interest.)
Name
(First, Middle, Last)		 SSN/TIN Birthdate Title Complete Address
(Street, City, State, Zip)
% Ownership Interest
Table 3A
Relationship Disclosure (Each Other)
Are there any of the individuals disclosed in Table 3 above related to each other as a spouse, parent, child, or sibling?
Name
(From Table 3) 		How is person in Table 3
related to the other person who has ownership or controlling interest? 		Related to Name of Other Person
listed in Table 3?
Table 3B
Relationship Disclosure (Related to 4A)
Are any of the individuals disclosed in Section 3 related to any of the individuals disclosed in Table 4A as a spouse, parent, child, or sibling?
- Provide the following details. Use additional pages if necessary.
Name
(From Table 3) 		How is person in Table 3
rrelated to the person from 4A 		Related to Name of Person
listed in 4A
Table 4
Direct or Indirect Ownership of 5% or more in a Subcontractor Disclosure
Provide the following details about the Subcontractor.
Name of Subcontractor
(First, Middle, Last) 		SSN/TIN Birthdate Complete Address
(Street, City, State, Zip)		 % Ownership Interest
Table 4A
(If Yes to Section 4)
Provide the information below about any Person (individual or entity) with an Ownership or Control Interest, in any Subcontractor in which the provider/vendor has a 5% or more Ownership Interest or Indirect Ownership or Control Interest (See the definition of the following terms: Person (individual or entity) with an Ownership or Control Interest , Subcontractor and Indirect Ownership Interest.)
Name of Subcontractor
(From Table 4) 		Name of Person(s) with an ownership or control interest in the Subcontractor SSN/TIN of Person(s) with an ownership or control interest in the subcontractor Birthdate of Person(s) with an ownership or control interest in the Subcontractor Complete Address
(Street, City, State, Zip) of Person(s) with an ownership or control interest in the Subcontractor 		% Ownership Interest or Control
Table 5
Other Disclosing Entity Disclosure
Provide the following details. (See the definition of the following terms: Other Disclosing Entity and Ownership Interest.)
Name
(From Table 4) 		Name of other disclosing entity or other Medicaid Provider SSN/TIN of the other disclosing entity or other Medicaid Provider
Table 6
Business Transactions Disclosure
Provide the following details. (See the definition of Subcontractor.)
Name of Subcontractor TIN or SSN, of Subcontract Birthdate Complete Address
(Street, City, State, Zip)		 Transaction Amount
Table 7
Significant Business Transactions Disclosure
Provide the following details. (See the definition of the following terms: Subcontractor, Wholly-owned Supplier, and Significant Business Transactions.)
Type of entity
(Wholly Owned Supplier OR Subcontractor) 		Name TIN/SSN Birthdate Complete Address
(Street, City, State, Zip)		 Transaction Amount

Section B – Attestation

Name of Provider/Vendor (Disclosing Entity) Being Contracted:

Tax ID # of Provider/Vendor:

Complete Business Address (Street, City, State, Zip)

By signing below, I hereby certify that all information contained in this form is true, correct, and complete in all aspects. I understand that misleading, inaccurate, or incomplete data may result in a denial of participation or termination of an existing contract.

Name: (Print or Type: First/Middle/Last)

Title: : (Print or Type)

Authorized Signature:

Authorized Date:

Appendix A - Instructions
  1. Read all definitions and instructions outlined throughout this Form and then reference the definitions and instructions while completing the Form. Terms that have regulatory definitions, and in some cases helpful examples, are underlined throughout this Form. These Definitions can be found in Appendix B on page 6. Please review the applicable definitions before responding to the question.
  2. Answer all questions as of the current date.
  3. If there is no information to include, indicate “None” or “N/A” in the space provided. Do not leave blank spaces unless advised to do otherwise in the instructions. An incomplete Form will be returned to the provider/vendor.
  4. If more space is needed, please attach additional sheets.
  5. Business & Service Address: The address for corporate/legal entities must include, as applicable, the primary business address, every business location, and P.O. Box address. Individuals must provide their home address.
  6. This Form should be submitted at the time of contracting and within 35 calendar days of any change to the information reported on this Form. In addition, on an annual basis, provider/vendor must complete an attestation stating information reported is current (and, if not, provide updated information).
  7. Failure to submit the requested information may result in denial of a claim, a refusal to enter into a provider agreement or contract, or in termination of existing agreements and contract.

Appendix B - Definitions
Agent
Any person who has been delegated the authority to obligate or act on behalf of a provider. It also means any person who has express or implied authority to obligate or act on behalf of an entity (42 CFR 1001.1001).
Disclosing Entity
The provider or vendor contracting with LIBERTY (other than an individual practitioner).
Indirect Ownership Interest
An ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an Indirect Ownership Interest in the disclosing entity. It also means an ownership interest through any other entities that ultimately have an ownership interest in the entity in issue (42 CFR 1001.1001). (For example, an individual has a 10 percent ownership interest in the entity at issue if he or she has a 20 percent ownership interest in a corporation that wholly owns a subsidiary that is a 50 percent owner of the entity in issue.)
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.
Other Disclosing Entity
Any other 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. This includes:
  1. Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare;
  2. Any Medicare intermediary or carrier; and
  3. Any entity (other than an individual practitioner) 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.
Example: Other examples include pharmacies, group homes, radiology centers.
Ownership Interest
The possession of equity in the capital, the stock, or the profits of the disclosing entity. It also means an interest in:
  1. The capital, the stock or the profits of the entity, or
  2. Any mortgage, deed, trust or note, or other obligation secured in whole or in part by the property or assets of the entity.
Person with an Ownership or Control Interest
A person or corporation that:
  1. Has an ownership interest totaling 5 percent or more in a disclosing entity;
  2. Has an Indirect Ownership Interest equal to 5 percent or more in a disclosing entity;
  3. Has a combination of direct and Indirect Ownership Interests equal to 5 percent or more in a disclosing entity;
  4. Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity;
  5. Is an officer or director of a disclosing entity that is organized as a corporation; or
  6. Is a partner in a disclosing entity that is organized as a partnership?
Example: In order to determine percentage of ownership, mortgage, deed of trust, note, or other obligation, the percentage of interest owned in the obligation is multiplied by the percentage of the disclosing entity’s assets used to secure the obligation. For example, if A owns 10 percent of a note secured by 60 percent of the provider’s assets, A’s interest in the provider’s assets equates to 6 percent and must be reported. Conversely, if B owns 40 percent of a note secured by 10 percent of the provider’s assets, B’s interest in the provider’s assets equates to 4 percent and need not be reported.
Significant Business Transaction
Any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a provider’s total operating expenses.
Subcontractor
  1. 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
  2. An individual, agency, or organization with which a fiscal 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 firm).
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.

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