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SECTION D 1 PROVIDER OWNERSHIP AND CONTROL DISCLOSURE FORM Name of your Medical Service of Supply provider Ownership (as contained on your application i(Applicable to all Providers of items or services

How to fill out provider ownership and control

How to fill out provider ownership and control

1. Gather all necessary information about the provider's ownership and control.
2. Start by providing the legal name and address of the provider.
3. Specify the type of ownership, such as individual, partnership, or corporation.
4. If applicable, provide the names and addresses of all individuals or entities that have a financial interest in the provider.
5. Indicate the percentage of ownership or control held by each individual or entity.
6. Include any relevant documentation or supporting evidence, such as partnership agreements or stock certificates.
7. Ensure accuracy and completeness of the information provided.
8. Review the filled-out form for any errors or omissions before submitting it.

Who needs provider ownership and control?

1. Any healthcare organization or facility seeking accreditation or certification may need to fill out and provide the ownership and control information. This requirement is often applicable to hospitals, clinics, nursing homes, home health agencies, and other healthcare providers.

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What is provider ownership and control?

Provider ownership and control refers to the identification of individuals or entities that have an ownership interest or control over a healthcare provider, which includes information about shareholders, partners, and executive officers.

Who is required to file provider ownership and control?

Healthcare providers, including those participating in federal healthcare programs such as Medicare and Medicaid, are required to file provider ownership and control information.

How to fill out provider ownership and control?

To fill out provider ownership and control, providers must complete the relevant sections of the CMS-855 form or applicable state forms, providing detailed information about ownership interests, control relationships, and identifying information of owners and managing employees.

What is the purpose of provider ownership and control?

The purpose of provider ownership and control is to promote transparency and accountability in healthcare services, ensuring that entities participating in federal programs are properly vetted and meet ethical and legal standards.

What information must be reported on provider ownership and control?

Providers are required to report information including names, addresses, and ownership interests of individuals or entities, relationships among owners, and any managing employees associated with the provider.