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to an individual Covered Person. <br />3.54. Information on Ownership and Control. <br />(a) Provider shall disclose the following information to Health Plan upon Agreement execution, <br />upon request during the re -validation of enrollment process under 42 C.F.R. § 455.414, and within 35 business days <br />after any change in ownership of Provider: <br />(1) The name and address of any person (individual or corporation) with an ownership <br />or control interest in Provider; <br />(2) If Provider is a corporate entity, the primary business address, every business <br />location, and P.O. Box address; <br />(3) If Provider has corporate ownership, the tax identification number of the corporate <br />owner(s); <br />(4) If Provider is an individual, date of birth and Social Security Number; <br />(5) If Provider has a five percent ownership interest in any of its subcontractors, the tax <br />identification number of the subcontractor(s); <br />(6) Whether any person with an ownership or control interest in Provider is related by <br />marriage or blood as a spouse, parent, child, or sibling to any other person with an ownership or control interest in <br />Provider; <br />(7) If Provider has a five percent ownership interest in any of its subcontractors, whether <br />any person with an ownership or control interest in such subcontractor is related by marriage or blood as a spouse, <br />parent, child, or sibling to any other person with an ownership or control interest in Provider; and <br />(8) Whether any person with an ownership or control interest in Provider also has an <br />ownership or control interest in any managed care entity. <br />(b) Upon the request of Health Plan or HCA, Provider shall furnish to HCA, within 35 calendar <br />days of a request, full and complete business transaction information as follows: <br />(1) The ownership of any subcontractor with whom Provider has had business <br />transactions totaling more than $25,000.00 during the previous 12 month period ending on the date of the request; <br />and <br />(2) Any significant business transaction between Provider and any wholly owned <br />supplier or any subcontractor during the previous five year period ending on the date of the request. <br />Provider shall provide any further information needed or reasonably requested by Health Plan for the purpose of <br />satisfying Health Plan's HCA reporting requirements under the State Contract, or for the purpose of verifying or <br />screening for exclusion from federal or state health care programs, or for conviction of various criminal or civil <br />offences, among the individuals or entities who have an ownership or control interest in, or who are a managing <br />employee of, Provider. <br />(c) Upon request, Provider shall furnish to the Washington Secretary of State, the Secretary of <br />the US Department of Health and Human Services, the Inspector General of the US Department of Health and Human <br />Services, the Washington State Auditor, the Comptroller of the Currency, and HCA a description of the transaction <br />between Provider and a party in interest (as defined in Section 1318(b) of the Public Health Service Act) within 35 <br />PPA WA - Kittitas County Public Health - 05.07.2025 - ICMProviderAgreement_360268 Page 10 of 12 <br />