Ownership and control information a. The Department shall review the ownership and control disclosures submitted by the Contractor, and any subcontractors as required in 42 CFR §438.608(c).
Ownership and control information. Subcontractor shall, and shall ensure Provider complies with and submits to United disclosure of information in accordance with the requirements specified in 42 CFR Part 455, Subpart B (42 CFR §§ 455.100 – 106), as may be amended from time to time.
Ownership and control information. (a) List the name, title, address, and SSN for each office and/or individual who has direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more of the provider entity. List the name, Tax ID (TIN), and address of any organization, corporation, or entity having direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more in the provider entity. Attach additional pages as necessary to list all officers, owners, management and ownership entities. Name Title Address SSN/TIN Percentage
Ownership and control information. Subcontractor shall, and shall require Provider to comply with and submit to United disclosure of information in accordance with the requirements specified in 42 CFR Part 455, Subpart B (42 CFR §§ 455.100 – 106), as may be amended from time to time. Subcontractor and Provider must be screened and enrolled into the State’s Medicaid or CHIP program, as applicable, and submit disclosures to Department on ownership and control, significant business transactions, and persons convicted of crimes, including any required criminal background checks, in accordance with 42 CFR Part 455 Subparts B and E. Subcontractor and Provider must submit information related to ownership and control of subcontractors or wholly owned suppliers within thirty-five (35) calendar days of a request for such information in accordance with 42 CFR 455.105. Additionally, Subcontractor and Provider must cooperate with the Department for submission of fingerprints upon a request from the Department or CMS in accordance with 42 CFR 455.434.
Ownership and control information. (a) Who owns you? List the name, title, personal address, and social security number of each office and/or individual, or the TIN for an organization, having any ownership or controlling interest, that amounts to an ownership interest of 5 percent or more in the disclosing entity (your company) submitting this Provider Contract. 42 C.F.R. §455.100; 42 C.F.R. §455.104.
Ownership and control information. If applicable, Provider shall cooperate with Subcontractor and/or CCO in obtaining and providing information to DOM related to ownership and control, significant business transactions, and persons convicted of a criminal offense in compliance with§1128 of the Social Security Act, 42 USC §1320a-7 and 42 CFR Part 455, as amended and shall provide information upon request. Provider shall submit information related to ownership and control of subcontractors or wholly owned supplier within thirty-five (35) calendar days of a request for such information. By executing the Agreement, Provider certifies that neither Provider nor any of its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in any State or federal health care program or from participating in transactions by any State or federal department or agency. Subcontractor will terminate the Agreement upon becoming aware or receiving notice from DOM, whichever is earlier, that Provider is or has been excluded from participation in any State or federal health care program or by any State or federal agency.
Ownership and control information. If applicable, Provider shall cooperate with CCO in obtaining and providing information to DOM related to ownership and control, significant business transactions, and persons convicted of a criminal offense in compliance with§1128 of the Social Security Act, 42 USC §1320a- 7 and 42 CFR Part 455, as amended and shall provide information upon request. Provider shall submit information related to ownership and control of subcontractors or wholly owned supplier within thirty-five
Ownership and control information. Provider shall comply with and submit to Subcontractor and/or Health Plan disclosure of information in accordance with the requirements specified in 42 CFR Part 455, Subpart B (42 CFR §§ 455.100 – 106), as may be amended from time to time.
Ownership and control information. (a) List the name, title, address, and SSN for each office and/or individual who has direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more of the provider entity. List the name, Tax ID (TIN), and address of any organization, corporation, or entity having direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more in the provider entity. Attach additional pages as necessary to list all officers, owners, management and ownership entities. Name Title Address, City, Zip SSN/TIN Percentage (b) List those persons named in Item II (a) that are related to each other (spouse, parent, child, or sibling). Name Relationship SSN
