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lnstructions for the Medicaid Provider Disclosure Statement
<br />These instructions are for use with the Medicaid Provider Disclosure Statement. Definitions of the terms used in this
<br />form are included at the end of this document. Please answer all questions as of the current date.
<br />Completion and submission of this form is a federal and state requirement, and a condition of participation in Medicaid
<br />reimbursement. Full and accurate disclosure of ownership as well as financial, managerial, and controlling interests is
<br />required. Completion of this form is also required to notify the DSHS of changes to ownership, managing employees,
<br />and controlling interests. Failure to submit the requested information may cause the Department to refuse to enter into
<br />an agreement or contract with the individual and/or entity or to terminate existing agreements. These disclosures are
<br />required under42 CFR $455.104,42 CFR $455.105, and 42 CFR $455.106.
<br />lnstructions by Section:
<br />l. Enrollinq Provider'slnformation
<br />Complete this section with information about the provider entity. Specify the provider's name, (legal name reported
<br />to the IRS), the Federal Tax lD associated with the provider (FEIN or SSN), the National Provider ldentifier (NPl),
<br />and the Doing Business As (DBA) name, if applicable.
<br />ll. lndividuals with Ownership lnterest
<br />Complete this section with information about individuals who have direct or indirect ownership interest ol 5o/o or
<br />more of the provider listed in Section l. Reportorganizationalowners in Section lV. See the definitions section at
<br />the end of this document for instructions on how to compute ownership percentage.
<br />For each owner, specify the name, date of birth, Social Security number, percentage of ownership, street address,
<br />and the start date of ownership interest with the provider.
<br />lf the individual owner is related to another owner, a managing employee, or someone with controlling interest, list
<br />the related individual. Report the related individual only if the individual is a spouse, parent, child, or sibling.
<br />lll. Manaqinq Emplorees anel other Controllinq lnterests
<br />Complete this section with information about managing employees and controlling interests of the provider listed in
<br />Section l. lnclude the general manager, business manager, administrator, director, or other individual who
<br />exercises operatronal or managerial control over, or who directly or indirectly conducts the dayto-day operation of
<br />an institution, organization, or agency. Also list controlling interests including each member of the board of
<br />directors, agenis with the authority to act on behalf of the provider listed in Section l, and officers or directors of a
<br />provider entity that is organized as a corporation.
<br />For each individual listed, specify the name, date of birth, Social Security number, street address, and the start
<br />date of controlling or managerial interest with the provider listed in Section l.
<br />lf the individual owner is related to another owner, managing employee, or someone with controlling interest of the
<br />provider listed in Section l, list the related individual (s). Report the related individual only if the individual is a
<br />spouse, parent, child, or sibling.
<br />lV. Orqanizations with Ownership lnterest or Manaqement lnterest
<br />Complete this section with information about organizations that have direct or indirect ownership interest of 5o/o or
<br />more of the provider listed in Section l. Also include organizations that have management interest in the provider
<br />listed in Section l. See the definitions section at the end of this document for instructions on how to compute
<br />ownership percentage.
<br />For each organization listed, specifu the legal name (as reported to the IRS), Federal Tax lD (FEIN), check
<br />whether the organization has ownership or management interest in the provider listed in Section l, Doing Business
<br />As (DBA) name, if applicable, the first date the organization started with ownership interest (or management
<br />interest), the percentage of ownership (if applicable), and the primary business address.
<br />List mailing address (such as a PO Box) and the address for each business location if different from the Primary
<br />Business Address.
<br />V. Subcontractorlnformation
<br />Complete this section with information about each person who has an ownership or controlling interest in any
<br />subcontractor in which the provider listed in Section I has direct or indirect ownership of 5% or more.
<br />For each individual listed, specify the name, title, Social Security number, ownership percentage, and address for
<br />each individual with an ownership or controlling interest in a subcontractor.
<br />List any individuals with ownership or controlling interest in the provider listed in Section I that also has an
<br />ownership or controlling interest of 5% or more in any other entity.
<br />DSHS 27-094 (REV. 0212017)Page 6
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