Ownership and Control Interest Disclosure Statement – South Country Health Alliance

  • Ownership and Control Interest Disclosure Statement

  • Provider Type*
  • Format: (000) 000-0000.
  • Select the entity type that best describes your organization*

  • All disclosing entities must complete the following sections for all persons and businesses or organizations that meet any of the following criteria:

    • Have an ownership or control interest of 5% or more in this disclosing entity
    • Have an ownership or control interest in a subcontractor in which this disclosing entity has a direct or indirect ownership interest of 5% or more
    • Are a managing employee

    For a Person: If you list a person, you must include the person's date of birth, social security number (SSN) and residential (home) address.

    For a Business: If you list a business, you must include the business' federal tax ID (FEIN) and primary business address for every business location (including street address) and every PO box address.
  • Do you have a person or persons to disclose?

  • Person #1

  • Choose the answer that best describes your position.*
  • Date of Birth*
     / /
  • Relationship to any other person listed
  • Important dates to report
  • Hire date
     - -
  • Termination date
     - -
  • Add another person?

  • Person #2

  • Choose the answer that best describes your position.*
  • Date of Birth*
     / /
  • Relationship to any other person listed
  • Important dates to report
  • Hire date
     - -
  • Termination date
     - -
  • Add another person?

  • Person #3

  • Choose the answer that best describes your position.*
  • Date of Birth*
     / /
  • Relationship to any other person listed
  • Important dates to report
  • Hire date
     - -
  • Termination date
     - -
  • Do you have more than 3 persons to report?

  • To report more than 3 persons email compliance@mnscha.org.

  • Do you have a business or businesses to disclose?

  • Warning! You must disclose either a person in the previous section or a business in this section. You can do either or both, but you may not leave both sections blank.
    If you need to disclose a person, go back to the previous section, otherwise check Yes to disclose a business in this section.

  • Business #1

  • You are:*
  • Ownership or Control Interest*
  • Begin Date*
     - -
  • End Date
     - -
  • Add another business?

  • Business #2

  • You are:*
  • Ownership or Control Interest*
  • Begin Date*
     - -
  • End Date
     - -
  • Add another business?

  • Business #3

  • You are a(n):*
  • Ownership or Control Interest*
  • Begin Date*
     - -
  • End Date
     - -
  • Do you have more than 3 businesses to report?

  • To report more than 3 businesses email compliance@mnscha.org.

  • Complete the following information for each person, business or organization previously listed that has an ownership or control interest in any other Medicaid disclosing entity or for any entity that is otherwise required to disclose ownership and control information because of participation in Title V, XVIII or XX programs.
     
    If there is no other ownership or control interest for a person, business, or organization previous listed, this section is not required. Please proceed to the next step.

  • Entity #1

  • Add Another?

  • Entity #2

  • Do you have more than two entities to report?

  • To report more than 2 entities email compliance@mnscha.org.

  • Check the appropriate box for each of the following questions.

    Has any person having an ownership or control interest ever:

  • Been convicted of a criminal offense related to that person's involvement in any Medicare, Medicaid, Title XX or Title XXI program in Minnesota or any other state or jurisdiction?*
  • Had civil monetary penalties or assessments imposed under section 1128A of the Social Security Act?*
  • Been excluded from participation in Medicare or other State health care programs?*

  • Has any managing employee or agent ever:

  • Been convicted of a criminal offense related to that person's involvement in any Medicare, Medicaid, Title XX or Title XXI program in Minnesota or any other state or jurisdiction?*
  • Had civil monetary penalties or assessments imposed under section 1128A of the Social Security Act?*
  • Been excluded from participation in Medicare or other State health care programs?*

  • Complete the following for any "Yes" answer.

  • PCA Providers ONLY:

    Complete the following information for all residential properties you own, lease, or manage that could be or are used for providing home care services.

  • Do You Own, Lease or Manage the Property?*

  • I am signing this form electronically. My name as typed in the signature field is my legally binding signature. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. (MN Statutes 325L.02(h), 325L.05 and 325L.08)

    By signing below, I, an authorized officer (CEO, president) with authority to bind the entity, certify that:
    • The information on this form is true and correct.
    • I will notify South Country of any changes to this information.

  • Format: (000) 000-0000.
  • Date*
     - -
  • Should be Empty: