IV. OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) (Continued) B. Individual with Ownership Interest and/or Managing Control—Identification Information 1. Full legal name (Last) (Jr., Sr., etc.) (First) 2. Residence address (number, street) (City) 3. Social security number 4. Date of birth (Middle) (State) (Nine-digit ZIP code) 5. Driver’s license number or state-issued identification number (Attach a current and legible copy.) 6. Is the above individual related to any individual listed in Section IV, Table A (Page 7)? If yes, check the appropriate box and list name of individual: Spouse Parent Child Sibling Yes No Other (explain): Name of individual: 7. If the above individual is directly associated with the entity identified in Section I, what is this individual’s relationship with the applicant/provider? Check all that apply. 5% or greater owner Partner Director/officer, title: Managing employee Other (specify): 8. If the above individual is directly associated with an entity identified in Section III, indicate the name of that entity in the space below: a. Legal business name of entity as listed in Section III, Part A: b. What is this individual’s role with the entity reported in Section III? Check all that apply. 5% or greater owner Partner Director/officer, title: Managing employee Other (specify): C. Respond to the following questions: 1. Within ten years from the date of this statement, has the above individual been convicted of any felony or misdemeanor involving fraud or abuse in any government program? Yes No Yes No Yes No Yes No If yes, provide the date of the conviction (mm/dd/yyyy): 2. Within ten years from the date of this statement, has the above individual been found liable for fraud or abuse involving a government program in any civil proceeding? If yes, provide the date of final judgment (mm/dd/yyyy): 3. Within ten years from the date of this statement, has the above individual entered into a settlement in lieu of conviction for fraud or abuse involving any government program? If yes, provide the date of the settlement (mm/dd/yyyy): 4. Does the above individual currently participate, or has he or she ever participated, as a provider in the Medi-Cal program or in another state’s Medicaid program? If yes, provide the following information: NAME(S) STATE NPI AND/OR (LEGAL AND DBA) PROVIDER NUMBER(S) Do not leave any questions, boxes, lines, etc., blank. DHCS 6207 (rev. 2/08) Page __ of __ American LegalNet, Inc. www.FormsWorkflow.com IV. OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) (Continued) Name of individual listed in Section IV, Part B, Item 1: Yes 5. Has the above individual ever been suspended from a Medicare, Medicaid, or Medi-Cal program? No If yes, attach verification of reinstatement and provide the following information: CHECK APPLICABLE PROGRAM NPI AND/OR PROVIDER NUMBER(S) EFFECTIVE DATE(S) OF SUSPENSION DATE(S) OF REINSTATEMENT(S), AS APPLICABLE Medi-Cal Medicaid Medicare Medi-Cal Medicaid Medicare 6. Has the above individual’s license, certificate, or other approval to provide health care ever been suspended or revoked? Yes No If yes, include copies of licensing authority decision(s) and written confirmation from them that his or her professional privileges have been restored and provide the following information: EFFECTIVE DATE(S) OF WHERE ACTION(S) WAS TAKEN ACTION(S) TAKEN LICENSING AUTHORITY’S ACTION(S) 7. Has the above individual otherwise lost or surrendered his or her license, certificate, or other approval to provide health care while a disciplinary hearing was pending? Yes No If yes, attach a copy of the written confirmation from the licensing authority that his or her professional privileges have been restored and provide the following information: WHERE ACTION(S) WAS TAKEN ACTION(S) TAKEN EFFECTIVE DATE(S) OF LICENSING AUTHORITY’S ACTION(S) 8. Has the above individual’s license, certificate, or other approval to provide health care ever been disciplined by any licensing authority? Yes No If yes, include copies of licensing authority decision(s), including any terms and conditions for each decision, and provide the following information: WHERE ACTION(S) WAS TAKEN ACTION(S) TAKEN EFFECTIVE DATE(S) OF LICENSING AUTHORITY’S ACTION(S) 9. List the name and address of all health care providers, participating or not participating in Medi-Cal, in which the above individual also has an ownership or control interest. If none, check here. If additional space is needed, attach additional page (label “Additional Section IV, Part C, Item 9”). Number of pages attached: a. Full legal name of health care provider (include any fictitious business names) b. Address (number, street) • (City) (State) (Nine-digit ZIP code) Proceed to Section V. Do not leave any questions, boxes, lines, etc., blank. DHCS 6207 (rev. 2/08) Page __ of __ American LegalNet, Inc. www.FormsWorkflow.com