Get the free Medicaid Provider Disclosure Statement - DSHS

AGING AND LONGER SUPPORT ADMINISTRATION DEVELOPMENTAL DISABILITIES ADMINISTRATION BEHAVIORAL HEALTH AND SERVICE INTEGRATION ADMINISTRATION Medicaid Provider Disclosure Statement Completion and submission

How to fill out medicaid provider disclosure statement

How to fill out medicaid provider disclosure statement

1. To fill out the Medicaid provider disclosure statement, follow these steps:
2. Begin by providing your personal information, including your name, address, phone number, and email address.
3. Indicate the type of provider you are, such as an individual practitioner, group practice, or facility.
4. Provide your Medicaid provider number, if applicable.
5. Specify the services you offer as a Medicaid provider.
6. Disclose any ownership or control interests in other healthcare facilities or providers.
7. Declare any financial relationships you have with pharmaceutical companies or medical device manufacturers.
8. Answer questions related to past criminal convictions or disciplinary actions.
9. Provide any additional information or explanations as required.
10. Review the completed form for accuracy and completeness before submitting it.
11. Sign and date the disclosure statement.
12. Submit the filled out form to the appropriate Medicaid authority or agency.

Who needs medicaid provider disclosure statement?

1. Medicaid providers of various types need to fill out the Medicaid provider disclosure statement.
2. This includes individual practitioners, group practices, and healthcare facilities.
3. Any healthcare provider who is enrolled in the Medicaid program and provides services to Medicaid beneficiaries is required to submit this disclosure statement.
4. It helps to ensure transparency and accountability in Medicaid program participation.

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What is medicaid provider disclosure statement?

The medicaid provider disclosure statement is a form that providers must submit to disclose certain information.

Who is required to file medicaid provider disclosure statement?

Providers who participate in the medicaid program are required to file the disclosure statement.

How to fill out medicaid provider disclosure statement?

Providers can fill out the medicaid provider disclosure statement by entering the required information accurately.

What is the purpose of medicaid provider disclosure statement?

The purpose of the medicaid provider disclosure statement is to ensure transparency and compliance with regulations.

What information must be reported on medicaid provider disclosure statement?

Providers must report information such as ownership, financial interests, and any other relevant disclosures.