III. OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ENTITIES) (Continued) B. Entity with (Direct or Indirect) Ownership Interest and/or Managing Control—Identification Information. 1. Legal business name 2. Doing Business As (DBA) name (if applicable) N/A 3. Address (number, street) (City) (State) (Nine-digit ZIP code) 4. Check all that apply: 5% or more ownership interest Managing control Partner Other (specify): 6. Effective date of control (mm/dd/yyyy) 5. Effective date of ownership (mm/dd/yyyy) C. Respond to the following questions: 1. Within ten years from the date of this statement, has this entity 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 this entity been found liable for fraud or abuse involving any 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 this entity 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 this entity currently participate, or has this entity ever participated, as a provider in the Medi-Cal program or in another state’s Medicaid program? If yes, provide the following information: NPI AND/OR NAME(S) (LEGAL AND DBA) STATE PROVIDER NUMBER(S) 5. Has this entity ever been suspended from a Medicare, Medicaid, or Medi-Cal program? Yes 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. List the name and address of all health care providers, participating or not participating in Medi-Cal, in which this entity also has an ownership or control interest. If none, check here. If additional space is needed, attach additional page (label “Additional Section III, Part C, Item 6”). Number of pages attached:____ a. Full legal name of health care provider (include any fictitious business names) b. Address (number, street) • (City) Proceed to Section IV. Do not leave any questions, boxes, lines, etc., blank. DHCS 6207 (rev. 2/08) (State) (Nine-digit ZIP code) Page __ of __ American LegalNet, Inc. www.FormsWorkflow.com