Disclosure of Ownership and Management Information, Business Transactions & Exclusions Statement for Providers
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1 Disclosure of Ownership and Management Information, Business Transactions & Exclusions Statement for Providers I. Instructions This statement should be completed and submitted to each of the health plans listed on Section VII. This statement must be submitted by the deadline set by each of the health plans, and a new statement must be submitted when any information in your original statement has changed. You should complete this form in conjunction with review of the requirements for: () disclosure of ownership; () exclusions of individuals and entities from government programs as set forth in each of the health plan s administrative requirements; and ) Significant Business Transactions. This statement must be completed whether or not you have any information to report. If more space is needed, please attach additional information. For assistance in completing this statement, please reference the Definitions provided under Section VII. II. Identifying Information LEGAL NAME ACCORDING TO THE IRS DBA (Doing Business As) ADDRESS NPI/UMPI CITY STATE ZIP CODE OFFICE PHONE NUMBER ( ) FEDERAL EMPLOYER ID (FEIN) MN TAX ID III. Structure Check the entity type that describes your structure: Sole Proprietorship Partnership Corporation Limited Liability Co. Non-Profit Public State Other Partnership (i.e., LP, LLP, LLLP) June 04 of 5
2 IV. Ownership & Control Interests A. Please provide the following information for each Managing Employee and Person with an Ownership or Control Interest in you as a Provider, or in any Subcontractor in which you as a Provider have direct or indirect ownership of 5% of more. If no such ownership exists, please indicate this with an N/A. No. Full Legal Name Address Date of Birth SSN or FEIN % Ownership Interest B. If any Person with an Ownership or Control Interest listed in subsection IV (A) is related to another Person with an Ownership or Control Interest listed in subsection IV (A) as a spouse, parent, child or sibling, please provide the following information. If no such relationship exists, please indicate this with an N/A. No. Full Legal Name SSN or FEIN Name of Person Related To Related Person s SSN or FEIN Relationship C. For each Person with an Ownership or Control Interest listed in subsection IV(A) who also has an ownership or control interest in an organization other than that indicated in subsection IV(A), please provide the following information. If no such ownership exists, please indicate this with an N/A. No. Full Legal Name Address SSN or FEIN Name of Other Organization % Ownership Interest June 04 of 5
3 V. Significant Business Transactions A. Please report your ownership of any Subcontractor with whom you as a Provider have had business transactions totaling more than twenty-five thousand dollars ($5,000) during the previous twelve () month period ending on the date of this request. If no such ownership exists, please indicate this with an N/A. No. Name of Subcontractor Address SSN or FEIN % Ownership Interest B. Please report any Significant Business Transactions between you as a Provider and any Wholly Owned Supplier, or between you as a Provider and any Subcontractor, during the previous five (5) year period ending on the date of this request. If no such business transactions exist, please indicate this with an N/A. No. Name of Wholly- Owned Supplier Address SSN or FEIN Nature of Business Transaction VI. Excluded Individuals or Entities A. Are there any employees, Persons with an Ownership or Control Interest in you as a Provider, or any of your Managing Employees or Agents who are or have ever: Been excluded from participation in Medicare or any of the State health care programs? Yes No Been convicted of a criminal offense related to that person s involvement in any program under Medicare, Medicaid, Title XX, or Title XXI in Minnesota or any other state or jurisdiction since the inception of these programs? Yes No Had civil money penalties or assessments imposed under Section 8A of the Social Security Act? Yes No June 04 of 5
4 B. Do you as a Provider have any agreements for the provision of items or services related to the health plan s obligations under its contract with the Department of Human Services or the Centers for Medicare and Medicaid Services with an individual or entity who: (i) ) has been excluded from participation in Medicare or any of the State health care programs; (ii) has been convicted of a criminal offense related to that person s involvement in any program under Medicare, Medicaid, Title XX, or Title XXI in Minnesota or any other state or jurisdiction since the inception of these programs; or (iii) had civil money penalties or assessments imposed under Section 8A of the Social Security Act? Yes No If you answered Yes to any of the above questions, list the name and social security number or Tax ID of the individual or entity, and reason for answering Yes (i.e., conviction of a criminal offense related to involvement in or exclusion from participation in Medicare, Medicaid, or other federally funded government health care programs, or imposition of civil money penalties or assessments under Section 8A of the Social Security Act). No. Full Legal Name SSN or FEIN Reason VII Certification and Submission I am authorized to bind the entity and I certify that the above information is true and correct. I will notify each of the health plans listed below of any changes to this information. NAME (Print) TITLE SIGNATURE DATE ADDRESS Return a completed, signed statement to each of the following: Blue Plus to: DisclosureStatement@bluecrossmn.com Mail to: Blue Cross and Blue Shield of Minnesota P. O. Box Route R7-GP St. Paul, MN Questions: or HealthPartners to: ananth.x.narayanee@healthpartners.com Fax to: Mail to: HealthPartners June 04 4 of 5
5 ATTN: Compliance Business Analyst Mail Stop 08C 870 RD Avenue South Bloomington, MN Questions: Medica Health Plans to: Fax to: Mail to: Medica Health Plans Mail Route CP45 40 Carlson Parkway Minneapolis, MN Questions: Metropolitan Health Plan Fax to: Mail to: MHP 400 South Fourth Street, Suite 0 Minneapolis, MN 5545 Attn: Front Desk. Questions: UCare to: PNM_FAX@UCare.org Fax to: Mail to: UCare P.O. Box 5 Minneapolis, MN Questions: VIII. DEFINITIONS For the purpose of this statement, the following definitions apply:. Agent means any person who has been delegated the authority to obligate or act on behalf of the Provider.. Managing Employee means an individual (including a general manager, business manager, administrator, or director) who exercises operational or managerial control over the Provider, or part thereof, or who directly or indirectly conducts the day-to-day operations of the Provider, or part thereof.. Person with an Ownership or Control Interest means a person or corporation that: A) has an ownership interest, directly or indirectly, totaling 5% or more in the Provider; B) has a combination of direct and indirect ownership interests equal to 5% or more in the Provider; C) owns an interest of 5% or more in any mortgage, deed of trust, note, or other obligation secured by the Provider, if that interest equals at least 5% of the value of the property or assets of the Provider; or D) is an officer or director of the Provider (if organized as a corporation) or is a partner in the Provider (if organized as a partnership). 4. Provider means an individual or entity that has entered into an agreement with any of the health plans listed on page 4 of this statement and is engaged in the delivery of health care services and is legally authorized to do so by the state in which it delivers the services. June 04 5 of 5
6 5. Subcontractor means an individual, agency, or organization to which the Provider has contracted (or a person with an employment, consulting or other arrangement with the Provider) for the provision of items and services that are significant and material to the Provider s contract with any of the health plans listed on page 4 of this statement and to that health plan s obligations under its contract with the Department of Human Services. 6. Significant Business Transaction means any business transaction or series of transactions that, during any one fiscal year, exceed the less of $5,000 and 5% of the Provider s total operating expenses. 7. Wholly Owned Supplier means a supplier (i.e., an individual, agency, or organization from which a Medicaid provider purchases good and services used in carrying out its responsibilities under Medicaid) whose total ownership interest is held by a Medicaid provider or by a person, persons, or other entity with an ownership or control interest in a Medicaid provider. June 04 6 of 5
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