Business Transactions. Subcontractors: Has the Provider Entity had any business transactions with a Subcontractor totaling more than $25,000 in the previous twelve (12) month period? Yes No-Skip to #9 N/A-Skip to #9 If yes, list the information for Subcontractors with whom the Provider Entity has had business transactions totaling more than $25,000 during the previous 12 month period ending on the date of this request (42 CFR §455.105(b)(1)) Attaching additional sheets as necessary - Yes No Name of Subcontractor: Subcontractor’s SSN or TIN: Subcontractor Address: City, State, Zip: Subcontractors Owner (SO): SO’s SSN or TIN: SO’s Address: City, State, Zip:
Appears in 5 contracts
Samples: Medicaid Managed Specialty Supports and Services Agreement, Substance Use Disorder Prevention Services Contractual Agreement, Recovery Contractual Agreement
