DC DHHS Disclosure of Owneship and Control free printable template

Disclosure of Ownership and Control Interest Statement Department of Health and Human Services Form Approved Health Care Financing Administration OMB No.0938-0086 I. Identifying Information D/B/A

How to fill out DC DHHS Disclosure of Owneship and Control

How to fill out DC DHHS Disclosure of Owneship and Control Interest

1. Obtain the DC DHHS Disclosure of Ownership and Control Interest form from the official website or relevant office.
2. Fill in the basic information at the top of the form, including your name, address, and contact information.
3. Indicate your role within the organization, such as owner, officer, or director.
4. Provide detailed information about the organization, including the business name, address, and tax identification number.
5. List all individuals and organizations that have an ownership or control interest in the entity, including their names and percentages of ownership.
6. Disclose any familial relationships that may exist among the individuals listed.
7. Answer questions regarding any legal actions or convictions related to the individuals with ownership or control interest.
8. Review the completed form for accuracy and completeness.
9. Sign and date the form at the designated section.

Who needs DC DHHS Disclosure of Owneship and Control Interest?

1. Entities that participate in or are applying for participation in programs funded by the Department of Health and Human Services (DHHS) in Washington, D.C.
2. Owners, officers, and directors of businesses that provide services to DHHS.
3. Individuals or organizations seeking contracts or grants from the DHHS.

People Also Ask about

What is the form for Medicare for retirees?

Form SSA-1 | Information You Need To Apply For Retirement Benefits Or Medicare. You can apply: Online; or. By calling our national toll-free service at 1-800-772-1213 (TTY 1-800-325-0778) or visiting your local Social Security office.

What is the OMB 0938 0930 form?

OMB 0938-0930 Medicare beneficiaries will use the "Medicare Authorization to Disclose Personal Health Information" to authorize Medicare to diclose their protected health information to a third party.

What forms do I need to fill out for Medicare Part B?

Fill out Form CMS-40B (Application for Enrollment in Medicare Part B). Send the completed form to your local Social Security office by fax or mail. Call 1-800-772-1213. TTY users can call 1-800-325-0778.

What is form CMS L564 for?

This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.

What is the OMB form 0938 0787?

This information is needed to determine whether an individual is eligible to enroll in Medicare Part B or Premium Part A under the provisions of section 1837(i) of the Social Security Act (The Act) and/or qualify for a reduction in the premium amount under the provisions of section 1839(b) of the Act.

What is form 40B?

This form is your application for Medicare Part B (Medical Insurance). You can use this form to sign up for Part B: During your Initial Enrollment Period (IEP) when you're first eligible for Medicare. During the General Enrollment Period (GEP) from January 1 through March 31 of each year.

For pdfFiller’s FAQs

How can I get DC DHHS Disclosure of Owneship and Control?

It’s easy with pdfFiller, a comprehensive online solution for professional document management. Access our extensive library of online forms (over 25M fillable forms are available) and locate the DC DHHS Disclosure of Owneship and Control in a matter of seconds. Open it right away and start customizing it using advanced editing features.

How do I edit DC DHHS Disclosure of Owneship and Control straight from my smartphone?

You can do so easily with pdfFiller’s applications for iOS and Android devices, which can be found at the Apple Store and Google Play Store, respectively. Alternatively, you can get the app on our web page: https://edit-pdf-ios-android.pdffiller.com/. Install the application, log in, and start editing DC DHHS Disclosure of Owneship and Control right away.

Can I edit DC DHHS Disclosure of Owneship and Control on an Android device?

With the pdfFiller Android app, you can edit, sign, and share DC DHHS Disclosure of Owneship and Control on your mobile device from any place. All you need is an internet connection to do this. Keep your documents in order from anywhere with the help of the app!

What is DC DHHS Disclosure of Ownership and Control Interest?

DC DHHS Disclosure of Ownership and Control Interest is a form used to disclose the ownership and control interests of individuals and entities involved in providing healthcare services under the Washington D.C. Department of Health Care Finance (DHCF) programs.

Who is required to file DC DHHS Disclosure of Ownership and Control Interest?

Providers of healthcare services who participate in the DHCF programs are required to file the DC DHHS Disclosure of Ownership and Control Interest.

How to fill out DC DHHS Disclosure of Ownership and Control Interest?

To fill out the DC DHHS Disclosure of Ownership and Control Interest, you need to provide details about the ownership structure, including names, titles, and percentages of ownership, as well as the control interests of individuals and entities related to the healthcare service provider.

What is the purpose of DC DHHS Disclosure of Ownership and Control Interest?

The purpose of the DC DHHS Disclosure of Ownership and Control Interest is to ensure transparency and accountability in the healthcare system, preventing fraud and abuse by enabling the DHCF to review the ownership and control of entities providing services.

What information must be reported on DC DHHS Disclosure of Ownership and Control Interest?

The information that must be reported includes the names, addresses, and identifying information of all owners and controlling individuals, the nature of their ownership interests, and any business affiliations that may affect their control or management of the healthcare provider.