Disclosure Of Ownership And Control Interest Statement Form. This is a Utah form and can be use in Department Of Health Statewide.
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UTAH MEDICAID DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT INSTRUCTIONS: Please complete the following information that is applicable to you. If the information requested does not apply, leave blank. See definitions of ownership and controlling interest. I. Identifying Information Name of Entity/Individual D/B/A Street Address NPI City, County, State Telephone Number ZIP Code Date of Birth MM/DD/YY II. Answer the following questions by checking “Yes” or “No”. If any of the questions are answered “Yes”, list names and addresses of individuals or corporations. List additional names and addresses under “Remarks” on Page 2. Identify each item number to be continued. See definition of ownership and controlling interest. A. Are there individuals or organizations having a direct or indirect ownership or control interest of 5 percent or YES NO more in the institution, organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons, or organizations in any of the programs established by Titles XVIII, XIX, or XX? Name Address Name Address B. Are there any directors, officers, agents, or managing employees of the institution, agency or organization who YES NO have ever been convicted of a criminal offense related to their involvement in such programs established by Titles XVIII, XIX, or XX? Name Address Name Address III. List name, address and SSN for all managing employees. List additional names, addresses and SSN under “Remarks” on Page 2. Social Security Date of Birth Name Address Number MM/DD/YY IV. List names, addresses for individuals, SSN and the EIN for organizations having direct or indirect ownership or a controlling interest in the entity of 5 percent or more. If more than one individual is reported and any of these persons are related to each other, i.e., spouse, parent, child, or sibling, this must be reported. List additional names and addresses under “Remarks” on Page 2. SSN Individual Date of Birth Name Address Relationship EIN Corporation MM/DD/YY A. Type of Entity: Sole Proprietorship Unincorporated Association Partnership Corporation Other (Specify) B. If the disclosing entity is a corporation, list names, addresses of the Directors, and EINs for corporations. List additional names and addresses under “Remarks” on Page 2. Name Address EIN February 14, 2011 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com C. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities? (Example, sole proprietor, partnership or members of Board of Directors.) If yes, list names, addresses of individuals and NPI numbers, list additional names, addresses and NPI under “Remarks” on Page 2. Name Address YES NO A. Has there been a change in ownership or control within the last year? If yes, when? B. Do you anticipate any change in ownership or control within the year? If yes, when? C. Do you anticipate filing for bankruptcy within the year? If yes, when? YES NO YES NO YES NO YES NO YES NO NPI V. VI. Is this facility operated by a management company, or leased in whole or part by another organization? If yes, when? Give date of change in operations. VII. Has there been a change in Administrator, Director of Nursing or Medical Director within the last year? YES VIII. Is this facility affiliated to a chain? (If yes, list name, address of Corporation, and EIN.) Name Address NO EIN IX. List owners of subcontractors that you have had business transactions with totaling more than $25,000 during the past 12 months. Name Address EIN WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE FALSE STATEMENT OR REPRESENTATION OF THIS STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY PARTICIPATES, ATERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR THE SECRETARY, AS APPROPRIATE. Name of Authorized Representative (Printed or Typed) Title Signature Date Telephone Number REMARKS (add additional sheets if necessary): February 14, 2011 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com