The Disclosure of Ownership and Control Interest Statement form collects information as required by federal regulation (42 CFR Part §455). This federal regulation is applicable to all providers that participate in state-based health care programs such as Medicaid and Children’s Health Insurance Program (CHIP) and provide services pursuant to a contract between a Medicaid Managed Care Organization (MCO) and a State Medicaid agency.
- All providers must disclose the information requested on the form prior to participation in the SecureCare Network.
- Disclosure information must be updated within 35 days of any change in information AND at least once every three (3) years.
- Disclosure forms must be completed, to include date of birth and social security numbers where indicated on the form. Any section that does not pertain to you must be marked with “N/A”.
- If you have already completed the form for another managed care organization you may send SecureCare a copy of the same disclosure as long as it is accurate and less than three (3) years old.
- For providers: Only the person disclosing the information can sign the form. Keep in mind that signature stamps are not acceptable.
- For provider entities: the signature must be that of an individual with the power to legally bind the entity i.e. an owner or an officer. Note: office manager/assistants signatures are not acceptable.
- Be sure to answer all of the questions on the form. If you answer “yes” to any of the questions, please include all the additional information required for those questions.
- If you have additional information to share you may submit an attachment or an addendum to the form.
- Collection of Social Security numbers is required by federal regulations (Sect. 4313 of the Balanced Budget Act of 1997, amended Sect. 1124 and Federal Register Vol. 76 No. 22 for further information). SSN’s are handled only by a limited number of SecureCare staff who are trained to keep the information confidential and who are bound by confidentiality policy and procedures.
- For more information on the provider Disclosure of Ownership and Control Interest Statement Form check out: www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/edmic-landing.html on the CMS website.