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Vl. CriminalOffenses
<br />Complete this section with information about each individual who has ownership, controlling interest, is an agent,
<br />managing employee, officer, or member of the board of directors of the provider listed in Section I and has been
<br />convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid, or
<br />Title XVlll, XlX, or XX, since the inception of those programs.
<br />For each individual listed, specify the name, Social Security number, ownership percentage (if applicable), and
<br />address.
<br />Vll. Suspension or Debarment
<br />Complete this section with information about each individualwho is an officer, owner, agent, or managing
<br />employee of the provider listed in Section I who has been suspended or debarred from participation in Medicare,
<br />Medicaid, ortheTitleXvlll, XlXorXXservices programs. These individualswould have been placed on the
<br />federal Office of the lnspector General, Health and Human Services (OIG/HHS) exclusions list, or on the System
<br />for Award Management (SAM). The current lists to excluded individuals can be found at:
<br />http://exclusions.oiq.hhs"qovlsea and https:l/www.sam.qov.
<br />For each individual listed, specify the name, Social Security number, ownership percentage (if applicable), and
<br />address.
<br />Vlll. Status Chanqes
<br />lndicate any anticipated changes within the next year.
<br />lX. Siqnature
<br />Provide the name and title of the individual completing statement, along with the signature and the date the
<br />statement is signed.
<br />Definitions
<br />Agent: Any person who has been delegated the authority to obligate or act on behalf of a provider.
<br />Exclusion: ltems and services furnished, ordered or prescribed by a specified individual or entity will not be reimbursed
<br />under Medicare, Medicaid, and all other federal health care programs until the individual or entity is reinstated by the
<br />orG.
<br />lndirect ownership interest: An ownership interest in an entity that has an ownership interest in the disclosing entity.
<br />This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.
<br />Managing employee: A general manager, business manager, administrator, director, or other individual who exercises
<br />operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution,
<br />organization, or agency
<br />OIG: Office of lnspector General of the Department of Health and Human Services.
<br />Ownership interest: The possession of equity in the capital, stock, or profits of the disclosing entity.
<br />Person with an ownership or control interest
<br />A person or corporation that:
<br />(a) Has an ownership interest totaling 5 percent or more in a disclosing entity.
<br />(b) Has an indirect ownership interest equalto 5 percent or more in a disclosing entity. (c) Has a combination of
<br />direct and indirect ownership interests equal to 5 percent or more in a disclosing entity.
<br />(d) Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the
<br />disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing
<br />entity.
<br />(e) ls an officer or director of a disclosing entity that is organized as a corporation.
<br />(f) ls a partner in a disclosing entity that is organized as a partnership.
<br />Subcontractor
<br />(a) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its
<br />management functions or responsibilities of providing medical care to its patients.
<br />(b) An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase
<br />order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the
<br />Medicaid agreement.
<br />DSHS 27-094 (REV. 02/2017)Page 7
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