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JUL AGING AND LONG-TERM SUPPORT ADMINISTRATION "'°"'°�'°^ 5f1e DEVELOPMENTAL DISABILITIES ADMINISTRATION Departmento[social /11 8Hea11h5ervices BEHAVIORAL HEALTH AND SERVICE INTEGRATION ADMINISTRATION Transforming lives Medicaid Provider Disclosure Statement Completion and submission of this form is a federal and state requirement and a condition of participation in Medicaid reimbursement (see instructions for specific citations). Full and accurate disclosure of ownership as well as financial, managerial, and controlling interests is required. Submission of this form to DSHS is also required for changes in ownership, managing employees, or controlling interests. Any failure to submit the requested information may cause the Department to refuse to enter into an agreement or contract with the individual or entity, or to terminate existing agreements. See the instructions for definitions of the terms used in this form. Please answer all questions as of the current date. If additional space is needed use an attached sheet. Sections: I. Identifying Information of Provider Entity Il. Individuals with Ownership Interest 111. Managing Employees and other Controlling Interests IV. Organizations with Ownership or Management Interest V. Subcontractor Information I. Enrolling Provider's Information see instructions PROVIDER NAME (LEGAL NAME) DOING BUSINESS AS (DBA) II. Individuals with Ownership Interest (see instructions) VI. Criminal Offenses VII. Suspension or Debarment Vlll. Status Changes Ix. Signature FEDERAL TAX ID: SSN / FEIN NATIONAL PROVIDER IDENTIFIER (NPI) List each individual who has direct or indirect ownership, separately or in combination, amounting to an ownership interest of 5% or more of the provider listed in Section I. Attach additional pages as necessary. FIRST NAME I LAST NAME DATE OF BIRTH SOCIAL SECURITY NUMBER I START DATE k .OWNERSHIP PERCENTAGE STREET NAME AND NUMBER, SUITE, ROOM, CITY STATE ZIP CODE If the individual being disclosed is related (spouse, parent, child, sibling) to another owner, managing employee, or individual with controlling interest of the provider listed in Section I, list related individual(s): FIRST NAME LAST NAME RELATIONSHIP FIRST NAME LAST NAME RELATIONSHIP List each individual who has direct or indirect ownership, separately or in combination, amounting to an ownership interest of. 5% or more of the provider listed in Section I. Attach additional pages as necessary. FIRST NAME I LAST NAME I DATE OF BIRTH SOCIAL SECURITY NUMBER I START DATE f OWNERSHIP PERCENTAGE STREET NAME AND NUMBER, SUITE, ROOM, ETC. CITY STATE ZIP If the individual being disclosed is related (spouse, parent, child, sibling) to another owner, managing employee, or individual with controlling interest of the provider listed in Section I, list related individual(s): FIRST NAME [LAST NAME RELATIONSHIP FIRST NAME ST NAME RELATIONSHIP DSHS 27-094 (REV. 02/2017) Page 1