FCHP - MassHealth Federally Required Disclosure secure form

A. Identification Information

All applicants, bidders, disclosing entities, fiscal agents, and providers, including MCEs, must complete this section.

Name:

*

Address:

*

(Individuals must provide their home address. Legal entities must provide, as applicable, their primary business address, every business location, and post office box addresses.)

Provider ID/Service Location (PID/SL) for existing MassHealth providers:

*

Contact Person:

*

Title:

*

Phone number:

*

Email address:

*

B: Ownership and Control

All applicants, bidders, disclosing entities, fiscal agents, and providers, including MCEs, must complete this section, unless otherwise directed by MassHealth.

(1) List the name and address of any person (individual or legal entity) with an ownership or control interest in the entity providing these disclosures, or with an ownership or control interest in any subcontractor in which the disclosing entity has a direct or indirect ownership of five percent or more. Provide the date of birth and SSN (for individuals identified), or other TIN (for legal entities identified), and complete the additional requested information. If there is no person or entity in this category, please respond “None.”

(a) Name:

Address: (Individuals must provide their home address. Legal entities must provide, as applicable, their primary business address, every business location, and post office box addresses.)

SSN or TIN:

Date of Birth (if an individual):

The individual or legal entity identified above has an ownership or control interest in which entity(ies): The entity providing these disclosures? Yes No

The individual or legal entity identified above has an ownership or control interest in which entity(ies): A subcontractor in which the disclosing entity has a direct or indirect ownership of five percent or more? Yes No

Name and address of the subcontractor: (Individuals must provide their home address. Legal entities must provide, as applicable, their primary business address, every business location, and post office box addresses.)

SSN or TIN of the subcontractor:

(b) Name:

Address: (Individuals must provide their home address. Legal entities must provide, as applicable, their primary business address, every business location, and post office box addresses.)

SSN or TIN:

Date of Birth (if an individual):

The individual or legal entity identified above has an ownership or control interest in which entity(ies): The entity providing these disclosures? Yes No

The individual or legal entity identified above has an ownership or control interest in which entity(ies): A subcontractor in which the disclosing entity has a direct or indirect ownership of five percent or more? Yes No

Name and address of the subcontractor: (Individuals must provide their home address. Legal entities must provide, as applicable, their primary business address, every business location, and post office box addresses. Attach a separate sheet if additional space is needed.)

SSN or TIN of the subcontractor:

2. Identify any individuals or legal entities named in question 1 as having an ownership or control interest, who are related to each other as spouse, parent, child, or sibling. Identify any individuals or legal entities named in question 1 as having an ownership or control interest, who are related to each other as spouse, parent, child, or sibling; and identify the particular relationship. If there are no such relationships, please respond “None.”

3. Identify any individuals or legal entities listed in question 1 as having an ownership or control interest, who also have an ownership or control interest in any other disclosing entity.

Identify any individuals or legal entities listed in question 1 as having an ownership or control interest, who also have an ownership or control interest in any other disclosing entity (or fiscal agent or MCE), and provide the name of each such other disclosing entity. If there are no individuals or legal entities with such interest, please respond “None.”

(a) Name:

Other Entity Name:

Other Entity Address:

(b) Name:

Other Entity Name:

Other Entity Address:

4. Identify and provide the following information for each managing employee.

If there are no managing employees, please respond “None.”

(a) Managing Employee:

Address:

SSN:

Date of Birth:

(b) Managing Employee:

Address:

SSN:

Date of Birth:

(c) Managing Employee:

Address:

SSN:

Date of Birth:

C. Business Transactions

Complete this section only if MassHealth directs you to do so. (Applicants and fiscal agents do not need to complete this section.)
1. Identify the ownership of any subcontractor with whom the provider, including an MCE, has had business transactions totaling more than $25,000 during the 12-month period before the date of this request. If there are multiple owners or shareholders, list only those with direct or indirect ownership of five percent or more. If there are no such business transactions to report, please respond “None.”

(a) Subcontractor:

Address:

SSN or TIN:

(i) Name of Owner:

Address:

(ii) Name of Owner:

Address:

(b) Subcontractor

Address:

SSN or TIN:

(i) Name of Owner:

Address:

(ii) Name of Owner:

Address:

2. Identify any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor during the five-year period before the date of this request. If there are no significant business transactions to report, please respond “None.”

D. Criminal Convictions

Applicants, bidders, and providers, including MCEs, must complete this section, unless otherwise directed by MassHealth. Provide the requested information in this section for any person who (1) (a) has an ownership or control interest in the disclosing applicant, bidder, MCE or provider, or (b) is an agent or managing employee of the disclosing applicant, bidder, MCE or provider; and (2) has also been convicted of a criminal offense related to any program under Medicare, Medicaid, or Title XX services since the inception of those programs. If there are no persons with such interest, please respond “None.” Attach a separate sheet if more space is needed.

Person 1 - Name:

Address:

Relationship:

Conviction information - Crime(s):

Conviction information - Date of Conviction:

Person 2 - Name:

Address:

Relationship:

Conviction information - Crime(s):

Conviction information - Date of Conviction:

E. Relationships to Excluded, Penalized, or Convicted Persons in accordance with 42 CFR §1002.3

All bidders, applicants, providers, including MCEs, must complete this section, unless otherwise directed by MassHealth. For definitions and additional information to complete this section, see the Disclosure form terms and definitions.

Person 1 - Name:

Address:

Relationship:

Conviction information - Crime(s)

Conviction information - Date of conviction:

Penalty or assessment information - Reason(s):

Penalty or assessment information - Date penalty or assessment imposed:

Exclusion information (Medicare) - Reason(s):

Exclusion information (Medicare) - Date of exclusion:

Exclusion information (state health care program) - State(s):

Exclusion information (state health care program) - Reason(s):

Exclusion information (state health care program) - Date of exclusion:

Person 2 - Name:

Address:

Relationship:

Conviction information - Crime(s)

Conviction information - Date of conviction:

Penalty or assessment information - Reason(s):

Penalty or assessment information - Date penalty or assessment imposed:

Exclusion information (Medicare) - Reason(s):

Exclusion information (Medicare) - Date of exclusion:

Exclusion information (state health care program) - State(s):

Exclusion information (state health care program) - Reason(s):

Exclusion information (state health care program) - Date of exclusion:

F. Provider/Fiscal Agent/MCE/Applicant, Bidder Attestation, Signature, and Date

All providers, fiscal agents, MCEs, and applicants must complete this section. I certify that the information on this form, and any attached statement that I have provided, has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I understand that I sign under the pains and penalties of perjury, and may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein. Provider’s/disclosing entity’s/fiscal agent’s/MCE’s/applicant’s/bidder’s signature (signature and date stamps, or the signature of anyone other than the provider/fiscal agent, applicant, bidder, or in the case of a legal entity, person legally authorized to sign on behalf of the entity are not acceptable.)

Electronic Signature: Yes

*

I certify that the information on this form, and any attached statement that I have provided, has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I understand that I sign under the pains and penalties of perjury, and may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein

Date:

Name:

*

Title:

*

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Federally Required Disclosures

A. Identification Information

B: Ownership and Control

3. Identify any individuals or legal entities listed in question 1 as having an ownership or control interest, who also have an ownership or control interest in any other disclosing entity.

4. Identify and provide the following information for each managing employee.

C. Business Transactions

D. Criminal Convictions

E. Relationships to Excluded, Penalized, or Convicted Persons in accordance with 42 CFR §1002.3

F. Provider/Fiscal Agent/MCE/Applicant, Bidder Attestation, Signature, and Date

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