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-Orr <br />fifir 0epartntrnl of social <br />& ilcnllh serli{es <br />AGING AND LONG-TERM SUPPORT ADMINISTRATION <br />DEVELOPMENTAL DISABILITIES ADMINISTRATION <br />BEHAVIORAL HEALTH AND SERVICE INTEGRATION ADMINISTRATION <br />Medicaid Provider Disclosure Statementfantfntmihg Iives <br />FIRST NAME <br />FIRST NAME <br />lf the individual being disclosed is related (spouse, parent, child, sibling)to anotherowner, managing employee, or <br />individual with controlling interest of the provider listed in Section l, list related individual(s): <br />STREET NAME AND NUMBER, SUITE, ROOM, ETC.CITY STATE ZIP CODE <br />SOCIAL SECURITY NUMBER <br />FIRST NAME <br />List each individual who has direct or indirect ownership, separately or in combination, amounting to an ownership <br />interest of 5o/o or more of the provider listed in Section l. Attach additional pages as necessary. <br />FIRST NAME <br />FIRST NAME <br />lf the individual being disclosed is related (spouse, parent, child, sibling) to another owner, managing employee, or <br />individual with controlling interest of the provider listed in Section l, list related individual(s): <br />STREET NAME AND NUMBER, SUITE, ROOM, ETC.CITY STATE ZIP CODE <br />SOCIAL SECURITY NUMBER <br />FIRST NAME <br />List each individual who has direct or indirect ownership, separately or in combination, amounting to an ownership <br />interest of Soh or more of the provider listed in Section l. Attach additional pages as necessary. <br />ll. lndividuals with Ownership lnterest (see instructions) <br />DOING BUSINESS AS (DBA) <br />PROVIDER NAME (LEGAL NAME) <br />l. Enrolling Provider's lnformation (see instructions) <br />Completion and submission of this form is a federal and state requirement and a condition of participation in Medicaid <br />reimbursement (see instructions for specific citations). Full and accurate disclosure of ownership as well as financial, <br />managerial, and controlling interests is required. Submission of this form to DSHS is also required for changes in <br />ownership, managing employees, or controlling interests. Any failure to submit the requested information may cause the <br />Department to refuse to enter into an agreement or contract with the individual or entity, or to terminate existing <br />agreements. See the rnstructions for definitions of the terms used in this form. <br />Please answer all questions as of the current date. lf additional space is needed use an attached sheet. <br />Sections: <br />l. ldentifuinq lnformation of Provider Entitv Vl. Criminal Offenses <br />ll lndividuals with Ownership lnterest Vll. Suspension or Debarment <br />Vlll. Status Chanqeslll. Manaqing Emplovees and other Controllinq lnterests <br />lV. Orqanizations with Ownership or Manaqement lnterest <br />V. Subcontractor lnformation <br />lX. Siqnature <br />LAST NAME <br />LAST NAME <br />START DATE <br />LAST NAME <br />LAST NAME <br />LAST NAME <br />START DATE <br />LAST NAME <br />RELATIONSHIP <br />RELATIONSHIP <br />OWNERSHIP PERCENTAGE <br />DATE OF BIRTH <br />RELATIONSHIP <br />RELATIONSHIP <br />OWNERSHIP PERCENTAGE <br />DATE OF BIRTH <br />NATIONAL PROVIDER IDENTIFIER (NPI) <br />FEDERAL TAX ID: SSN / FEIN <br />DSHS 27-094 (REV. o2l2017)Page 1