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to an indMdual CoveredPerson. 3.54. Information on Ownership and Control. (a) Provider shall disolose the foilowing information to Health Plan upon Agreffnent execution, upon request during the re-validation of enrollment proccss under 42 C.F,R, g 455,414, and within 35 business days after any ohange in ownership of Provider: (1) The name ancl address of any person (individual or corporation) with an ownership or control interest in Provider; @ If Provider is a corporate entity, the primary business address, every business location, and P.O. Box address; (3) If Provider has corporate ownership, the tax identification number of the corporate owneds); (4) IfProvider is an individual, date of birth and Social Seourity Number; (5) If Provider has a five percent ownership interest in any of its subconhactors, the tax identification number of the subcontractor(s); (6) Whether any person with an ownership or control interest in Provider is related by marriage or blood as a spouse, parsnt, child, or sibling to any other person with an ownership or control interest in Provider; (7) ffProvider has a five percent ownership interest in any of its subcontractors, whether any person with an ownership or control interest in such zubcontractor is related by marriage or blood as a spouse, parent, chiid, or sibling to any other person with an ownership or control interest in Provider; and (8) WhEther any person with an ownership or control interest in Provider also has an ownership or control intsrest in any managed care entity. (b) Upontherequest of HealthPlan orHC,{ Provider shall fumishto HCA, within 35 calendar days of a request, firll and complete business hansaction information as follows: (1) The ownership of any subcontractor with whom Provider has had business transactions totaling more than $25,000,00 during the previous 12 month period ending on the date of the request; and (2) Any significant business transaction between Provider and any wholly owned supplier or arLy subcontractor during the previous five year period ending on tlre date of the request. Provider shall provide any firther fuformation needed or reasonably requested by Health Plan for the purpose of satisfying Health Plan's HCA reporting requirements undsr the State Contract, or for the purpose of verifying or screening for exclusion from federal or state health care programs, or for conviction of various criminal or civil offences, among the individuals or entities who have an ownership or control interest in, or who are a managing employee of, Provider. (c) Upon request, Provider shall furnish to the Washington Secretary of State, the Secretary of the US Department of Health and I-Iuman Services, the Inspector General of the US Department of l-Iealth and Human Services, the Washing;on State Auditor, the Comptroller of the Currency, and HCA a description of the transaction between Provider and a party in interest (as deftred in Section 1318(b) of the trublic Health Service Act) within 35 PPAWA-KittitasCountyPublicl{ealth-05.07.2025-lCMProviderAgreernent 360268 Pagel0ofl2