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STARK i 1. APPLY! CAT ION NU “1BER 7J.....:::.&.!.7 3 '/.!... 2. OPERATOR ') l 'o. J c '!), ::TIV : './ LTT., ., LL, 0 e J.:::.:X:l:LFL/ 'a. /..... '2. J 3. API f:j 4. PERMIT# REISSUE COUNTY Initials
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How to fill out Stark I-1:

01
Gather all relevant information: Start by collecting all the necessary information required to fill out the Stark I-1 form. This may include details about the parties involved in the financial relationship, the nature of the relationship, and any existing agreements or arrangements.
02
Complete the identification section: Begin by filling out the identification section of the form, which includes entering the names, addresses, and contact information of the parties involved. Ensure that all details are accurate and up to date.
03
Provide details about the nature of the financial relationship: In this section, you will need to describe the specific nature of the financial relationship between the parties. This may entail providing information about any leases, loans, or contracts, as well as detailing the services rendered or compensation involved.
04
Report any exceptions or additional information: If there are any exceptions or additional relevant information that need to be disclosed, make sure to include them in this section. It is essential to be thorough and transparent when filling out the form.
05
Sign and date the form: Once you have filled out all the necessary sections of the Stark I-1 form, ensure that you sign and date it appropriately. This signature signifies that the information provided is accurate and complete to the best of your knowledge.

Who needs Stark I-1?

01
Healthcare Providers: Health professionals, medical practices, hospitals, and clinics may need to fill out the Stark I-1 form if they have financial relationships with other entities, such as referring physicians, suppliers, or other healthcare businesses.
02
Supplier and Service Providers: Companies or individuals supplying goods or services to healthcare providers may require the completion of the Stark I-1 form if they have a financial relationship that falls under the Stark law regulations.
03
Medicare and Medicaid Participants: Healthcare providers and suppliers participating in the Medicare or Medicaid programs may be required by law to complete the Stark I-1 form to ensure compliance with the Federal Stark law, which prohibits certain self-referral practices that may result in the overutilization of medical services.
Overall, anyone involved in a financial relationship within the healthcare industry should familiarize themselves with the Stark I-1 form requirements and may need to complete it accordingly. Compliance with the Stark law is crucial to avoid potential legal ramifications.
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Stark I 1 is a form used for reporting financial relationships between healthcare providers and referring physicians.
Healthcare providers are required to file Stark I 1 if they have financial relationships with referring physicians.
Stark I 1 can be filled out by providing information about the financial relationships between healthcare providers and referring physicians.
The purpose of Stark I 1 is to ensure transparency and monitor potential conflicts of interest in healthcare referrals.
Information such as the nature of the financial relationship, the parties involved, and the value of the relationship must be reported on Stark I 1.
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