Fillable F0001 Provider Application

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F0001 Provider Application

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  • 35 check-boxes
  • 200 other fields

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STATE OF MARYLAND
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
MEDICAL CARE PROGRAM
PROVIDER APPLICATION
Please fill in the requested information as completely as possible. The following form definitions are provided to help clarify the information
requested.
Should you have any questions please contact the Provider Enrollment Unit at (410) 767-5340.
NOTE: PLEASE ATTACH A COPY OF ALL REQUESTED
DOCUMENTS
1
1) APPLICATION TYPE
Check the appropriate box. If the request is to change existing data, then you
must also include your Medicaid Provider Number. If you have already
rendered service please indicate a Requested Enrollment Begin Date. The
Provider Enrollment Unit will backdate your application up to (3) months
prior to its receipt date. The enrollment begin date for an approved application
is based on the date the application is received in our office.
2) PROVIDER INFORMATION
If you have a business, such as pharmacy or medical supply, or a professional
group, enter the company name or corporate group name. All physicians and
other individual practitioners should enter last name, first name, middle initial
and professional title.
Enter the address, telephone and fax number of your primary practice
location, contact person name and their telephone number and the practice
email or website address. Enter a “Y” for Yes or a “N” for No if your office is
handicap accessible.
Enter the appropriate two-digit code for county of your business or practice
location address. A listing of the county codes is provided for your reference
at the end of these instructions.
Enter the two-digit code for the appropriate provider type from the listing
provided at the end of these instructions. Applicants for the Kidney Disease
Program (KDP) must also enter the two-digit KDP code.
Enter the Federal Employer ID Number, National Provider Identification
(NPI) and the Social Security Number of the individual, group or business to
whom the Medicaid reimbursements will be made.
3) LICENSE/PERMIT INFORMATION
Enter your professional license number, beginning effective date and
expiration date for each practice location in which you service Maryland
Medicaid recipients. If out of state, attach a copy of the current license
certificate. Enter your NABP number if applicable.
Enter your Drug Enforcement Agency number and attach a copy of your DEA
certificate. If you do not have a DEA number, this box should be left blank.
Enter your pharmacy permit number, if applicable.
Medical laboratory providers, practitioners and other providers that perform
medical laboratory services MUST COMPLETE and SUPPLY the
following:
• Enter Clinical Laboratory Improvement Amendment (CLIA) #
• Attach a copy of CLIA Certificate
• Enter Maryland Laboratory Permit or Letter of Permit Exception #
• Attach copy of Maryland Laboratory Permit or Letter of Permit
Exception
Out-of-state providers that do not receive specimens originating in Maryland
do not have to supply Maryland certification information but do have to state
that they do not receive specimens originating in Maryland.
Practitioners providing laboratory services to OTHER THAN THEIR OWN
PATIENTS MUST enroll as medical laboratory providers.
4) PRACTICE INFORMATION
Enter the appropriate two-digit code for your type of practice. If this does not
apply, leave blank. For your reference, a listing of the practice codes is
provided at the end of these instructions.
If you are applying as an HMO, enter FR to indicate the type of contract as
Full Risk with Abortion or SL to indicate the type of contract as Stop Loss
without Abortion. In addition, please complete and sign the enclosed form
DHMH 4126-G located at the end of the application. Otherwise, leave this
blank.
5) SPECIALTY INFORMATION
Enter a “P” to designate the primary specialty. If multiple specialty codes are
entered, then you must designate one specialty as the primary specialty.
Physicians, Dentists, and Pharmacies MUST enter the appropriate three-digit
code from the specialty code listing provided at the end of these instructions.
Enter OTH if you have another specialty not listed. PLEASE SPECIFY.
Enter the date you were certified for your specialty in MMDDYY format.
Enter the number, up to six digits, that was provided to you when you were
certified for the associated specialty.
6) SPECIALTY VERIFICATION
Please check the applicable statement and attach the required documentation.
7) GROUP MEMBERSHIP INFORMATION
If you are a MEMBER OF A GROUP PRACTICE, please enter the name,
Maryland Medicaid provider number and the effective date you became a
member of the group. If you are a GROUP PRACTICE, please list the names
of each professional practicing in your group and his/her individual Maryland
Medicaid provider number and membership effective date. All practitioners in
the group MUST individually be enrolled as a Maryland Medicaid provider.
8) MEDICARE INFORMATION
If you participate in Medicare, please list the fiscal intermediaries with whom
you are enrolled (i.e. Blue Cross of Maryland, Traveler’s Group Hospital
Insurance, etc.) and enter the provider number each has assigned to you.
9) ALTERNATE ADDRESS INFORMATION
Enter the Pay-To-Address address, you want your Medicaid reimbursement
checks mailed. If you leave this section blank, your checks will be mailed to
the primary practice location entered on the first page of the application.
Enter the Correspondence Address you want all your Medicaid related
correspondence and remittance advices mailed. If you leave this area blank,
correspondence will be mailed to the primary practice location entered on the
first page of the application. Also, please indicate if you would like to receive
correspondence electronically. If yes, please include your email address on the
first page of the application.
10) OTHER PRACTICE LOCATION INFORMATION
Please enter other locations where you serve Maryland Medicaid recipients.
Include all group addresses where you are currently practicing. Enter a “Y”
for Yes or a “N” for No if your office is handicap accessible.
11) AUTHORIZATION
Please sign and date the application. No one can sign on your behalf.
Print Form
2
MEDICAL CARE PROGRAM -PROVIDER APPLICATION INSTRUCTIONS
PROVIDER TYPE CODES
AC Acupuncture- Children ONLY 51 EPSDT Therapeutic Intervention- Children
ONLY
23 Nurse Practitioner (Indiv. Or Group)
50 ADAA Certified Addictions
Outpatient Prog.
52 EPSDT Therapeutic Nursery 24 Nurse Psychotherapist (Indiv. Or Group)
T1 Ambulance Services 72 HealthChoice and PAC Managed Care
Organizations
57 Nursing Facility
39 Ambulatory Surgical Center 70 HMO 76 Older Adults Waiver Provider
40 Home and Community Based Services, Other 18 Occupational Therapist (Indiv. Or Group)- Children
ONLY
AT Attendant Care Waiver-Living at
Home Waiver Provider
41 Home Health Agency- Must be Medicare
Certified
63 Oxygen Services
19 Audiology Services Provider- Children
ONLY
71 Hospice Provider MH Partial Hospitalization Program
01 Hospital, Acute 44 Personal Care Aid
81 Case Management 03 Hospital, Rehabilitation Acute 45 Personal Care Aid Agency
CC Certified Professional Counselor 04 Hospital, Rehabilitation Chronic 47 Personal Care Monitor
82 Children’s Medical Services (CMS)
Provider
05 Hospital, Chronic RX Pharmacy
13 Chiropractor- Children ONLY 06 Hospital, Special Pediatric 16 Physical Therapist (Indiv. Or Group)
30 Clinic, Abortion 07 Hospital, Special Psychiatric 20 Physician (Indiv. Or Group)
55 Intermediate Care Facility-Addiction (ICF-
A)- Children ONLY
11 Podiatrist (Indiv. Or Group)
32 Clinic, Drug Abuse (Methadone) 59 Portable X-Ray
33 Clinic, Family Planning 10 Laboratories, Medical 15 Psychologist (indiv. Or Group)
34 Clinic, Federally Qualified Health
Center
91 Local Education Agencies/ Local Lead
Agencies
PR Psychiatric Rehab. Program
35 Clinic, Local Health Department 72 MCO (HealthChoice and PAC) 87 REM Providers
36 Clinic, Maryland Qualified Health
Centers
42 Medical Day Care, Adult 53 Residential Service Agency/ Home Health Aide
Provider/ Private Duty Nursing
37 Clinic, Rural Health 43 Medical Day Care, Children 92 Prescribing providers
38 Clinic, General MA Medicare Advantage Plan 93 Senior Center Plus
83 Comprehensive Outpatient
Rehabilitation Facility (CORF)
CM Mental Health Case Management Provider 94 Social Worker (Indiv. or Group)
90 DDA Services Provider MC Mental Health Clinic 17 Speech/Language Pathologist (Indiv. or Group)
14 Dental 27 Mental Health Group Provider
(Psychotherapist, Social Worker, Nurse
Psychotherapist)
95 State Agency
60 Diagnostic Services, Other 28 Therapy Group Provider (PT. OT. Speech)
61 Dialysis Facilities MT Mobile Treatment 86 Traumatic Brain Injury Waiver
85 Dietician/Nutritionists- Children and
Pregnant Women ONLY
21 Nurse Anesthetists (Indiv. Or Group) 08 Urgent Care Centers
62 DME/DMS 22 Nurse Midwife (Indiv. Or Group) 12 Vision Care
KIDNEY DISEASE PROGRAM
K1 Physician K6 Hospital- Inpatient
K2 Pharmacy K7 Medical Laboratory
K3 Dialysis Facility K8 Other (dental, vision)
K5 Hospital-Outpatient
TYPE OF PRACTICE CODES
35 Group Practice 99 Other
50 HMO 20 Pharmacy, single store
30 Individual Practice 21 Pharmacy chain, 2-10 stores
31 Individual Practice, L/P
hospital only
22 Pharmacy chain, 11+ stores
32 Individual Practice, Emerg.
Room only
23 Pharmacy, hospital based
33 Individual Practice, O/P or
clinic only
24 Pharmacy, nursing home based
10 Nursing Home 25 Pharmacy, tax supported
3
COUNTY CODES
01 Allegany 07 Cecil 13 Howard 19 Somerset 40 Washington, DC
02 Anne Arundel 08 Charles 14 Kent 20 Talbot 99 Other State
03 Baltimore County 09 Dorchester 15 Montgomery 21 Washington
04 Calvert 10 Frederick 16 Prince George’s 22 Wicomico
05 Caroline 11 Garrett 17 Queen Anne’s 23 Worchester
06 Carroll 12 Harford 18 St. Mary’s 30 Baltimore City
SPECIALTY CODES
PHYSICIAN SPECIALTY CODES
026 Allergy & Immunology 008 Gynecologic Oncology 019 Pediatric Critical Care Medicine
045 Anatomic & Clinical Pathology 035 Hematology 020 Pediatric Endocrinology
046 Anatomic Pathology 036 Infectious Disease 021 Pediatric Gastroenterology
041 Anesthesiology 030 Internal Medicine 022 Pediatric Hematology- Oncology
031 Cardiovascular Disease 009 Maternal & Fetal Medicine 023 Pediatric Nephrology
053 Child & Adolescent Psychiatry 037 Medical Oncology 024 Pediatric Pulmonology
047 Clinical Pathology 025 Neonatal- Perinatal Medicine 002 Pediatric Surgery
004 Colon& Rectal Surgery 038 Nephrology 016 Pediatric
032 Critical Care Medicine 014 Neurological Surgery 048 Physical Medicine & Rehabilitation
060 Dermatoligcal Immunology/ Diagnostic &
Laboratory Immunology
050 Neurology 011 Plastic Surgery
058 Dermatology 051 Neurology with Special Qualification in
Child Neurology
052 Psychiatry
059 Dermatopathology 044 Nuclear Medicine 049 Public Health & General Preventive
Medicine
017 Diagnostic Lab Immunology 057 Nuclear Radiology 039 Pulmonary Disease
055 Diagnostic Radiology 007 Obstetrics & Gynecology 056 Radiation Oncology
043 Emergency Medicine 015 Opthalmology 054 Radiology
033 Endocrinology & Metabolism 013 Orthopedic Surgery 010 Reproductive Endocrinology
029 Family Practice 183 Osteopath 040 Rheumatology
034 Gastroenterology 012 Otolaryngology 001 Surgery
028 General Practice 186 Pathology 005 Thoracic Surgery
003 General Vascular Surgery 018 Pediatric Cardiology 006 Urology
DENTAL SPECIALTY CODES
113 Dental- Other 181 Oral Surgery
123 Endodontics 182 Orthodontics
057 Nuclear Radiology 187 Pedodontics
131 General Dentistry 188 Periodontics
4
MEDICAL CARE PROGRAM—PROVIDER APPLICATION
IMPORTANT: PLEASE READ ATTACHED INSTRUCTIONS BEFORE COMPLETING APPLICATION
1) APPLICATION TYPE:
NPI: ______________________________
New Enrollment
Existing Provider/ Change Existing Provider Number: __________________________
I am applying as a….. Please check one:
Group of Practitioners
Individual Practitioner- Solo Practitioner or Member of a Group (Please circle type)
Facility/ Institution/ Business/ Agency (Please circle type)
2) PROVIDER INFORMATION
*Please refer to the instructions for the appropriate codes.
Group/Facility/ Business/ Agency Name: _______________________________________________
Physician/Practitioner Last Name: ________________________ First Name: ______________________ Title: __________________
Contact Person Name: __________________________ Phone Number: ________________ Email Address: ____________________
Primary Practice Address: _____________________________________________________ Suite Number: _______________
City: ______________________________ State: __________ Zip Code: ___________________ Handicap Access: ___________
Phone Number: ______________ Fax Number: _______________ County Code: ____________ Provider Type Code: ___________
Employer Identification Number: ______________ Name of EIN Owner: _________________ Social Security Number: __________
Medicare Provider Number: _______________________ National Provider Identification Number:
_______________________
3) LICENSE/PERMIT INFORMATION
License/ Permit Type
Individual Professional
: State Issued: ____ License/Permit Number: _______________ Date Issued:________ Expiration Date:
_________
DEA: State Issued: ____ License/Permit Number: _______________ Date Issued:_________ Expiration Date:_________
Good Standing: Yes: _____ No:______
Institutional:
MDLAB: State Issued: ____ License/Permit Number: _______________ Date Issued:_________ Expiration Date:_________
CLIA: State Issued: ____ License/Permit Number: _______________ Date Issued:_________ Expiration Date:_________
NABP: State Issued: ____ License/Permit Number: _______________ Date Issued:_________ Expiration Date:_________
Pharmacy: State Issued: ____ License/Permit Number: _______________ Date Issued:_________ Expiration Date:_________
NCPDP: State Issued: ____ License/Permit Number: _______________ Date Issued:_________ Expiration Date:_________
Good Standing: Yes: _____ No:______
4) PRACTICE INFORMATION
5
*Please refer to instructions for appropriate codes.
Type of Practice:________ HMO Type Category: ______________
5) SPECIALTY INFORMATION (IF APPLICABLE)
*Please refer to the instructions for appropriate codes.
Primary / Secondary Specialty: _____________________ Specialty Code: ________
Certification Date: ___________ Certification Number: ________________________
Primary / Secondary Specialty: _____________________ Specialty Code: ________
Certification Date: ___________ Certification Number: ________________________
Primary / Secondary Specialty: _____________________ Specialty Code: ________
Certification Date: ___________ Certification Number: ________________________
Primary / Secondary Specialty: _____________________ Specialty Code: ________
Certification Date: ___________ Certification Number: ________________________
Primary / Secondary Specialty: _____________________ Specialty Code: ________
Certification Date: ___________ Certification Number: ________________________
Primary / Secondary Specialty: _____________________ Specialty Code: ________
Certification Date: ___________ Certification Number: ________________________
Primary / Secondary Specialty: _____________________ Specialty Code: ________
Certification Date: ___________ Certification Number: ________________________
6) SPECIALTY VERIFICATION
Please check the applicable statement and attach the required documentation. Pursuant to the Physicians Services Regulations
(COMAR 10.09.02), the Medical Assistance Program defines a Consultant-Specialist as a licensed physician who meets one of the
following criteria:
___ I have been declared board certified by a member of the American Board of Medical Specialists and currently retain that status. A
photocopy of my specialty board certificate is attached.
___ I have satisfactorily completed a residency program accredited by the Liaison Committee for Graduate Medical Education or by
the appropriate residency review committee of the American Medical Association. Attached is a letter of verification from the
chairman of the department where I completed my residency or where I am now working. This letter includes the name of the hospital
where I completed my residency, length of my residency, by whom the program is accredited and the completion date of my
residency.
___ I have been declared board certified by a specialty board approved by the Advisory Board of Osteopathic Specialists and the
Board of Trustees of the American Osteopathic Association. A photocopy of my specialty board certificate is attached.
___ I have been declared board eligible by a specialty board approved by the Advisory Board of Osteopathic Specialists. Verification
from my specialty board that I am board eligible is attached.
___ I have completed a residency program in a foreign country. My qualifications and training are acceptable for admission in the
examination system of the appropriate American Specialty Board. A letter of my specialty board verifying this is attached.
If your application is for a group or professional association, each physician/practitioner in the group or association who wishes to be
considered a specialist must submit the required verification.
7) GROUP MEMBERSHIP INFORMATION
Group Name: ______________________ Provider Number: ________________________ Begin Date: _______________________
Group Name: ______________________ Provider Number: ________________________ Begin Date: _______________________
6
Group Name: ______________________ Provider Number: ________________________ Begin Date: _______________________
Group Name: ______________________ Provider Number: ________________________ Begin Date: _______________________
8) MEDICARE INFORMATION
Name: _________________________________________ Medicare Number: _____________________________________________
Name: _________________________________________ Medicare Number: _____________________________________________
Name: _________________________________________ Medicare Number: _____________________________________________
9) ALTERNATIVE ADDRESS INFORMATION
Pay To Address
Address: _______________________________________________________________________________________
City: ____________________________________________ State: __________________ Zip Code: _______________
Correspondence Address
Address: _______________________________________________________________________________________
City: ____________________________________________ State: __________________ Zip Code: _______________
Would you prefer to receive electronic correspondence, including remittance advices, in lieu of paper, when available?
Yes: _______ No: ________
10) OTHER PRACTICE LOCATION INFORMATION
Please enter other locations where you provide healthcare services for Maryland Medicaid recipients. Include all group addresses you
are currently practicing under, if applicable. *Please refer to the instructions for appropriate codes.
Practice Address #2
Primary Practice Address: _____________________________________________________ Suite Number: ___________
City: ______________________________ State: __________ Zip Code: ___________________ Handicap Access: ________
Phone Number: ____________________ County Code: _____________
License Number: _______________________ Expiration Date: ___________________________
Practice Address #3
Primary Practice Address: _____________________________________________________ Suite Number: ___________
City: ______________________________ State: __________ Zip Code: ___________________ Handicap Access: ________
Phone Number: ____________________ County Code: _____________
License Number: _______________________ Expiration Date: ___________________________
12) AUTHORIZATION
I, the practitioner, administrator or authorized professional representative of this group, hereby affirm that this information given by
me is true and complete to the best of my knowledge and belief. I understand that if I or my group is salaried by a hospital or other
institution for patient care, that I or my group will not bill the Maryland Medical Care Program for those services for which I or my
group is salaried.
7
Date: _______________________________________
Type Name of Practitioner, Administrator or
Authorized Professional Responsible for the Quality of Patient Care: __________________________________________
Signature of Practitioner, Administrator or
Authorized Professional Responsible for the Quality of Patient Care: __________________________________________
Signature of Owner (in the case of a Pharmacy: ______________________________________________
Please Return Completed Application to: Systems and Operations Administration,
Provider Enrollment
P.O. Box 17030
Baltimore, MD 21203
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8
PROVIDER APPLICATION PRACTITIONER AND GROUP ADDENDUM
PRACTITIONER
If you are participating in a group practice, do you also provide care to Maryland Medicaid recipients in your private practice and wish
to be reimbursed directly by the State (your personal tax identification number must appear on this application)?
Yes: No:
GROUP
If your group is affiliated with a health care institution or medical school, please enter the name and full address of the institution or
school, your title and a brief explanation of your group’s duties:
Name of Facility: ________________________________________________________________________
Address: _______________________________________________________________________________
Title: __________________________________________________________________________________
Duties: ________________________________________________________________________________
Is your group salaried by the above institution? Yes: No:
If you are a M.D. or D.O. will you be dispensing pharmaceuticals other than samples (as pharmacy)? Yes: No:
If you are an O. D., are you practicing optometry exclusively? Yes: No: or optometry as well as preparing and dispensing
eyeglasses (as an optician)? Yes: No:
Is your group operating a Local Health Department Clinic? Yes: No:
Is your group operating a Freestanding Clinic? Yes: No:
NOTE: All practitioners in a group must be enrolled as Medical Care Program rendering providers.
LABORATORY INFORMATION
Completion of this section is required by individual practitioners and groups. Reimbursement for medical laboratory services you
provide to eligible recipients are dependent on answering the following questions and supplying copies of CLIA Certificate and, when
required, Maryland Laboratory Permits or Letters of Permit Exception. Practitioner providers cannot be reimbursed for services
referred to medical laboratories or other practices. Those laboratories or practices must bill.
Do you provide medical laboratory services for your own patients? Yes: No:
Do you provide medical laboratory services for other than your own patients? Yes: No:
Do you receive specimens that are obtained from other sites located in Maryland? Yes: No:
All Maryland laboratories are required to have a Maryland Laboratory Permit or Letter of Permit Exception Number (§Health General
Article §17-205, Annotated Code of Maryland) and CLIA Certificate Number (Clinical Laboratory Improvement of 1988 Public Law
100-578) to perform laboratory services. Out-of-state providers are only required to provide their CLIA Certificate Number, if they do
not receive specimens that originate in Maryland.
BED DATA:
Intermediate Care (ICF) Number of Beds: _____________ Chronic Hospital (CHB) Number of Beds: _____________
Acute Inpatient (INP) Number of Beds: _____________ Mental Retardation (MR) Number of Beds: _____________
Skilled Nursing (SNF) Number of Beds: _____________ Other (OTH) Number of Beds: _____________
9
DIALYSIS FACILITIES
Medicare Provider Number: ___________________________________
Attach a copy of letter with assigned Medicare Provider Number.
Attach a copy of the letter(s) from your intermediary showing all current composite rates.
Note: You will be paid ONLY for the rate(s) appearing in this/these letter(s) in addition to those services provided, but not included in
the composite rate.
PORTABLE X-RAY AND OTHER DIAGNOSTIC SERVICES MUST SUPPLY THE FOLLOWING:
Maryland Medical Test Unit Permit No.: _________________________
Do you intend to bill for portability? Yes: No:
Note: All portable x-ray and other diagnostic service providers located within Maryland or serving patients located within Maryland
MUST have a Maryland Test Unit Permit. The only out-of-state portable x-ray and other diagnostic services providers that do not
have to have a Maryland Medical Test Unit Permit are those that serve Maryland Medical recipients in the State in which the provider
is located and they must provide a Medicare number.
LABORATORY INFORMATION
Completion of this section is required. Reimbursement for medical laboratory services you provide to eligible recipients is dependent
on answering the following questions and supplying copies of CLIA Certificate and, when required, a Maryland Laboratory Permits or
Letters of Permit Examination. Practitioner providers cannot be reimbursed for services referred to medical laboratories or other
practices. Those laboratories or practices must bill.
Do you provide medical laboratory services for your own patients? Yes: No:
Do you provide medical laboratory services for other than your own patients? Yes: No:
Do you receive specimens that are obtained from other sites located in Maryland? Yes: No:
All Maryland practitioners are required to have a Maryland Laboratory Permit or Letter of Permit Exception Number (§ Health
General Article 17-202 and 17-205, Annotated Code of Maryland) and CLIA Certificate Number (Clinical Laboratory Improvement
of 1988 Public Law 100-578) to perform laboratory services. Out-of-state providers are only required to provide their CLIA
Certificate Number, if they do not receive specimens that originate in Maryland.
10
PROVIDER OWNERSHIP AND DISCLOSURE FORM
(Applicable to all Providers of items or services
1
except for individual practitioners or groups of
practitioners
2
)
Provider Name: ______________________________________
Provider Address: _____________________________________
Pursuant to 42 CFR 455.100 et seq., the disclosure of the following is a required portion of the Maryland Medicaid Provider
Application. Therefore, please answer the following questions and sign this document affirming that this information is true and
complete, and return with your application.
A. Name any person, who, with respect to the Title XIX Provider
3
1. is an officer or director:
Name: ________________________________ Address: _______________________________________________
Name: ________________________________ Address: _______________________________________________
Name: ________________________________ Address: _______________________________________________
2. is a partner:
Name: ________________________________ Address: _______________________________________________
Name: ________________________________ Address: ___________________________________________
Name: _______________________________ Address: _______________________________________________
3. has direct or indirect ownership interest
4
of 5% or more:
Name: ________________________________ Address: _______________________________________________
1
“Provider” or “provider” of services means a hospital, a skilled nursing facility, an intermediate care facility, a clinic, a psychiatric
facility, a mental institution, an independent clinical laboratory, a health maintenance organization, a pharmacy, and any other entity
that furnishes or arranges for the furnishing of services for which payment is claimed under the Medicaid program. It does not include
individual practitioners or groups of practitioners.
2
“Group of practitioners” means two or more health care practitioners who practice their profession at a common location (whether or
not they share common facilities, common supporting staff, or common equipment) but who have not formed a partnership or
corporation and are not employees of a person, partnership or corporation, or other entity owning or operating the health care facilities
at which they practice.
3
Identify any persons named, who are related to others named, as spouse, parent, child or sibling.
4
a). “Ownership interest” means the possession of equity in the capital of, stock in, or of any interest in the profits of the disclosing
entity.
b) “Indirect ownership interest” means any ownership interest in an entity that has ownership interest in the disclosing entity. The
term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.
c) “Determination of ownership or control percentage”
1) Indirect ownership interest- The amount of indirect ownership interest is determined by multiplying the percentages of
ownership in each entity. For example, if A owns 10 percent of the stock in a corporation which owns 80 percent of the stock
of the disclosing entity, A’s interest equates to an 8 percent indirect ownership interest in the disclosing entity and must be
reported. Conversely, if B owns 80 percent of the stock of a corporation which owns 5 percent of the stock of the disclosing
entity, B’s interest equates to a 4 percent indirect ownership interest in the disclosing entity and need not be reported.
2) Person with an ownership or control interest- In order to determine percentage of ownership, mortgage, deed of trust, note,
or other obligation, the percentage of the disclosing entity’s assets used to secure the obligation. For example, if A owns 10
percent of a note secured by 60 percent of the provider’s assets, A’s interest in the provider’s assets equates to 6 percent and
must be reported. Conversely, if B owns 40 percent of a note secured by 10 percent of the provider’s assets, B’s interest in
the provider’s assets equates to 4 percent and need not be reported.
11
Name: ________________________________ Address: _______________________________________________
Name: ________________________________ Address: _______________________________________________
4. has a combination of direct or indirect ownership interests equal to 5% or more in the Provider
Name: ________________________________ Address: _______________________________________________
Name: ________________________________ Address: _______________________________________________
Name: ________________________________ Address: _______________________________________________
5. is an owner (in whole or in part) of an interest of 5% or more in any mortgage, deed of trust, note, or other
obligation secured (in whole or in part) by the Provider or its property or assets if that interest equals at least 5% of
the value of the property or assets of the Provider
Name: ________________________________ Address: _______________________________________________
Name: ________________________________ Address: _______________________________________________
Name: ________________________________ Address: _______________________________________________
B. With respect to any subcontractor in which the Title XIX Provider has, directly or indirectly, an ownership or control
interest of 5% or more, name any person who falls within Part A. 1-5 above, as applied to the subcontractor and specify
which of the above categories he falls within
Name: ________________________________ Category: _________________________________
Name: ________________________________ Category: _________________________________
Name: ________________________________ Category: _________________________________
C. 1. If any person named in response to Part A. 1-5, above, has any of the relationships described in that Part with any Title
XIX Provider of items or services other than the applicant, or with any entity that does not participate in Medicaid but is
required to disclose certain ownership and control information because of participation in any of the programs
established under Title V, XVII, or XX of the Social Security Act, state the name of the person, the name of the other
Provider, and the nature of the relationship.
Name: ________________________________Provider: ________________________
Relationship: ___________________________________
Name: ________________________________Provider: ________________________
Relationship: ___________________________________
Name: ________________________________Provider: ________________________
Relationship: ___________________________________
2. If the answer to Part C. 1. above, contains the names of more than two persons, state whether any of those so reported
are related to each other as spouse, parent, child or sibling
Relationship: ______________________
12
D. Name any person who has been convicted
5
of a criminal offense related to his involvement with any program operated
under Title XVIII, XIX, or XX of the Social Security Act, and who, with regard to the Title XIX Provider, falls within
the provisions of A.1-5, above, or is an agent or a managing employee [an individual, including a general manager,
administrator and director, who exercises operational or managerial control or who directly or indirectly conducts the
day-to-day operations]
Name: ________________________________
Name: ________________________________
Name: ________________________________
I hereby affirm that this information is true and complete to the best of my knowledge and belief, and that the requested
information will be updated as changes occur. I further certify that upon specific request by the Secretary of the Department of
Health and Human Services, or the Maryland Department of Health and Mental Hygiene, full and complete information will be
supplied within 35 days of the date of the request, concerning:
A. the ownership of any subcontractor with which the Title XIX Provider has had, during the previous 12 months, business
transactions in an aggregate amount in excess of $25,000.00 and
B. any significant business transactions
6
, occurring during the 5 year period ending on the date of such request, between the
Provider and any wholly-owned supplier
7
or any subcontractor.
AUTHORIZED SIGNATURE: __________________________________ DATE: _________________________
POSITION: ___________________________________________________
5
“Convicted” means that a judgment of conviction has been entered by a Federal, State, or local court, irrespective of whether an
appeal from that judgment is pending.
6
“Significant business transaction” means any business transaction or series of transactions that, during any one fiscal year, exceeds
the lesser of $25,000 or 5 percent of the total operating expense of a provider.
7
“Supplier” means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its
responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital bed, or a pharmaceutical firm).
13
FOR DHMH USE ONLY
Application Date: ________/ / ______
Eligibility Date: __________/______/______
Enrollment Status:
Category of Service Codes
Provider Activity Record
Date Initials Activity
14
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Completed 24 July 2020

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