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HEALTH SYSTEMS DIVISION Provider Enrollment Unit Oregon Medicaid (Oregon Health Plan)Provider Disclosure Statement of Ownership and Control, Business Transactions and Criminal Convictions All pages

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Review the provider disclosure statement form to understand the information required.

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Fill out all the sections of the form accurately and completely.

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Who needs provider disclosure statement form?

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Providers or healthcare professionals who are required to disclose certain information according to regulations or policy.

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What is provider disclosure statement form?

The provider disclosure statement form is a document required by certain regulations that requires healthcare providers to disclose specific information about their organization, ownership, and financial arrangements.

Who is required to file provider disclosure statement form?

Healthcare providers that participate in Medicare or Medicaid programs are typically required to file the provider disclosure statement form.

How to fill out provider disclosure statement form?

To fill out the provider disclosure statement form, gather all necessary information about the organization, ownership, and financial interests. Complete the form as per the provided instructions and ensure all information is accurate before submitting.

What is the purpose of provider disclosure statement form?

The purpose of the provider disclosure statement form is to ensure transparency and compliance with federal regulations by requiring providers to disclose relevant information that could affect healthcare decisions and reimbursements.

What information must be reported on provider disclosure statement form?

The form typically requires reporting information on ownership, controlling interests, affiliations, financial relationships, and any legal proceedings involving the provider.

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