DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT. I. Identifying Information
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT. Disclosing entity is defined as a Medicaid provider (other than an individual practitioner or group of practitioners), or a fiscal agent. Indirect ownership interest is defined as ownership interest in an entity that has direct or indirect ownership interest in the disclosing entity. The amount of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at each level. For example, if A owns 10 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing entity, A’s interest equates to an 8 percent indirect ownership and must be reported. Conversely, if B owns 80 percent of the stock of a corporation that owns 5 percent of the stock of the disclosing entity, B’s interest equates to a 4 percent indirect ownership interest in the disclosing entity and need not be reported. Controlling interest is defined as the operational direction or management of a disclosing entity which may be maintained by any or all of the following devices; the ability or authority, expressed or reserved to amend or change the corporate identity (i.e., joint venture agreement, unincorporated business status) of the disclosing entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of the disclosing entity; the ability or authority, expressed or reserved to amend or change the by-laws, constitution or other operating or management direction of the disclosing entity; the right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved to control the sale of any or all of the assets to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity or to arrange for the sale or transfer of the disclosing entity to new ownership or control. 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 a...
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT. ITEM III (a) List the name, title, address and SSN (TIN if an organization) of all individuals or organizations having a direct or indirect ownership or control interest of five (5) percent or more that was convicted of a criminal offense related to the involvement of such persons or organizations in any of the programs established under Medicare, Medicaid or the Title XX services program since the inception of those programs.
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT. A full and accurate disclosure of ownership and financial interest is required. Failure to submit requested information may result in a refusal by the Merced County Department of Mental Health and Alcohol and Drug Services (MHP) to enter into an agreement or contract with any such institution or in termination of existing agreements.
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT. Contractor shall comply with the requirements pertaining to the Disclosure of Ownership and Control Interest Statement contained in Exhibit M, “Program Integrity Requirements” and submit to County the “Disclosure of Ownership and Control Interest Statement” form, which is included herein as Exhibit J.
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT. Return the original and a copy to the Department of Elder Affairs retain a copy for your files. This form is to be completed annually. Any substantial delay in completing the form should be reported to the Department of Elder Affairs.
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT. A. Contractor agrees to furnish Behavioral Health with the names of its officers, owners, stockholders owning more than ten percent (10%) of its stock, and major creditors holding more than five percent (5%) of the debt of Contractor. This information shall become public record on file with the Department of Health and Human Services.
