Disclosure Information. (A) Using the Department-specified disclosure form, and in accordance with 42 CFR 455.104, the Contractor, if organized as a corporation, shall provide disclosures for each Person with an Ownership or Control Interest in the Contractor. (B) The disclosures for Persons with an Ownership or Control Interest shall include: (1) the person’s name and address of any Person (individual or corporation) with an Ownership or Control Interest in the Contractor. The address for corporate entities must include as applicable primary business address, every business location and the P.O. Box address; (2) date of birth and Social Security Number (in the case of an individual); (3) other tax identification number (in the case of a corporation) with an ownership or control interest in the Contractor or in any Subcontractor in which the Contractor has a five percent or more interest; (4) whether the Person (individual or corporation) with an Ownership or Control Interest in the Contractor is related to another Person with an Ownership or Control Interest in the Contractor as a spouse, parent, child, or sibling; (5) whether the Person (individual or corporation) with an Ownership or Control Interest in any Subcontractor in which the Contractor has a five percent or more interest is related to another person with an Ownership or Control Interest in the Contractor as a spouse, parent, child, or sibling; and (6) the name of any Other Disclosing Entity (or Fiscal Agent or Managed Care Entity) in which an owner of the Contractor has an ownership or control interest. (C) Using the Department-specified form, and in accordance with 42 CFR 455.104, the Contractor shall provide disclosures of Managing Employees that include the name, address, date of birth, and Social Security Number of any Managing Employee of the Contractor. (D) Government-owned Entities - If the Contractor is government-owned, the Contractor shall disclose anyone meeting the definition of a Managing Employee, and would only need to disclose board members if a board member meets the definition of a Managing Employee.
Appears in 7 contracts
Samples: Accountable Care Organization (Aco) Contract, Accountable Care Organization (Aco) Contract, Integrated Care Contract
Disclosure Information. (A) Using the Department-specified disclosure form’s Managed Care Entity Disclosure Form, and in accordance with 42 CFR 455.104, the Contractor, if organized as a corporation, Contractor shall provide disclosures for each require the following disclosures:
(1) Each Person with an Ownership or Control Interest in the Contractor.
(B) The disclosures for Persons with an Ownership or Control Interest Contractor shall includedisclose:
(1i) Identifying information that shall include the person’s name and address of any Person (individual or corporation) with an Ownership or Control Interest in the Contractor. The address for corporate entities must include as applicable primary business name, address, every business location and the P.O. Box address;
(2) date of birth and birth, Social Security Number (in the case of an individual);
(3) or other tax identification number (in the case of a corporation). An individual shall disclose the address of his or her primary residence. A corporate entity shall include (as applicable) with an ownership or control interest in the Contractor or in any Subcontractor in which the Contractor has a five percent or more interest;primary business address, every business location and P.O. Boxes; and
(4ii) whether the Whether that person is related to another Person (individual or corporation) with an Ownership or Control Interest in the Contractor is related to another Person with an Ownership or Control Interest in the Contractor as a spouse, parent, child, or sibling;.
(52) whether the Each Person (individual or corporation) with an Ownership or Control Interest in any a Subcontractor in which the Contractor has a five percent or more interest shall disclose:
(i) Identifying information that shall include the person’s name, address, date of birth, Social Security Number (in the case of an individual) or other tax identification number (in the case of a corporation). An individual shall disclose the address of his or her primary residence. A corporate entity shall include (as applicable) the primary business address, every business location and P.O. Boxes; and
(ii) Whether that person is related to another person Person with an Ownership or Control Interest in the Contractor as a spouse, parent, child, or sibling; and
(6) the name of any Other Disclosing Entity (or Fiscal Agent or Managed Care Entity) in which an owner of the Contractor has an ownership or control interest.
(C3) Using the Department-specified form, and in accordance with 42 CFR 455.104, the Contractor shall provide disclosures of Managing Employees shall disclose:
(i) Identifying information that shall include the name, address, date of birth, and Social Security Number of any Managing Employee of the Contractor.
(D4) Government-owned Entities - If Persons with an Ownership Interest in the Contractor shall disclose:
(i) Identifying information that shall include the name of the individual; and
(ii) the name of any Other Disclosing Entity (or Fiscal Agent or Managed Care Entity) in which the person with an Ownership Interest in the Contractor is government-ownedalso a Person with an Ownership or Control Interest in the Other Disclosing Entity (or Fiscal Agent or Managed Care Entity).
(5) In the event that the Contractor Subcontracts with an entity to perform administrative functions for the Contractor’s CHIP program, the Contractor shall require Persons with an Ownership or Control Interest in the Subcontractor to disclose anyone meeting the definition following information:
(i) Identifying information that shall include the person’s name, address, date of birth, Social Security Number (in the case of an individual) or other tax identification number (in the case of a corporation). An individual shall disclose the address of his or her primary residence. A corporate entity shall include (as applicable) the primary business address, every business location and P.O. Boxes; and
(ii) Whether that person is related to another Person with an Ownership or Control Interest in the Contractor is related to another Person with an Ownership or Control Interest in the Contractor as a spouse, parent, child, or sibling.
(6) In the event that the Contractor Subcontracts with an entity to perform administrative functions, for the Contractor’s CHIP program, the Contractor shall require Managing EmployeeEmployees of the Subcontractor to disclose the following information:
(i) Identifying information that shall include the name, address, date of birth, and would only need to disclose board members if a board member meets Social Security Number of any Managing Employee of the definition of a Managing EmployeeContractor.
Appears in 5 contracts
Samples: Chip Dentaquest Amendment 2, Chip Select Health Amendment 1, Chip Premier Access Dental Contract Amendment 2
Disclosure Information. (A) Using the Department-specified disclosure form’s Managed Care Entity Disclosure Form, and in accordance with 42 CFR 455.104, the Contractor, if organized as a corporation, Contractor shall provide disclosures for each require the following disclosures:
(1) Each Person with an Ownership or Control Interest in the Contractor.
(B) The disclosures for Persons with an Ownership or Control Interest Contractor shall includedisclose:
(1i) Identifying information that shall include the person’s name and address of any Person (individual or corporation) with an Ownership or Control Interest in the Contractor. The address for corporate entities must include as applicable primary business name, address, every business location and the P.O. Box address;
(2) date of birth and birth, Social Security Number (in the case of an individual);
(3) or other tax identification number (in the case of a corporation). An individual shall disclose the address of his or her primary residence. A corporate entity shall include (as applicable) with an ownership or control interest in the Contractor or in any Subcontractor in which the Contractor has a five percent or more interest;primary business address, every business location and P.O. Boxes; and
(4ii) whether the Whether that person is related to another Person (individual or corporation) with an Ownership or Control Interest in the Contractor is related to another Person with an Ownership or Control Interest in the Contractor as a spouse, parent, child, or sibling;.
(52) whether the Each Person (individual or corporation) with an Ownership or Control Interest in any a Subcontractor in which the Contractor has a five percent or more interest shall disclose:
(i) Identifying information that shall include the person’s name, address, date of birth, Social Security Number (in the case of an individual) or other tax identification number (in the case of a corporation). An individual shall disclose the address of his or her primary residence. A corporate entity shall include (as applicable) the primary business address, every business location and P.O. Boxes; and
(ii) Whether that person is related to another person Person with an Ownership or Control Interest in the Contractor as a spouse, parent, child, or sibling; and
(6) the name of any Other Disclosing Entity (or Fiscal Agent or Managed Care Entity) in which an owner of the Contractor has an ownership or control interest.
(C3) Using the Department-specified form, and in accordance with 42 CFR 455.104, the Contractor shall provide disclosures of Managing Employees shall disclose:
(i) Identifying information that shall include the name, address, date of birth, and Social Security Number of any Managing Employee of the Contractor.
(D4) Government-owned Entities - If Persons with an Ownership Interest in the Contractor shall disclose:
(i) Identifying information that shall include the name of the individual; and
(ii) the name of any Other Disclosing Entity (or Fiscal Agent or Managed Care Entity) in which the person with an Ownership Interest in the Contractor is government-ownedalso a Person with an Ownership or Control Interest in the Other Disclosing Entity (or Fiscal Agent or Managed Care Entity).
(5) In the event that the Contractor Subcontracts with an entity to perform administrative functions for the Contractor’s CHIP program, the Contractor shall require Persons with an Ownership or Control Interest in the Subcontractor to disclose anyone meeting the definition following information:
(i) Identifying information that shall include the person’s name, address, date of birth, Social Security Number (in the case of an individual) or other tax identification number (in the case of a corporation). An individual shall disclose the address of his or her primary residence. A corporate entity shall include (as applicable) the primary business address, every business location and P.O. Boxes; and
(ii) Whether that person is related to another Person with an Ownership or Control Interest in the Contractor is related to another Person with an Ownership
(6) In the event that the Contractor Subcontracts with an entity to perform administrative functions, for the Contractor’s CHIP program, the Contractor shall require Managing EmployeeEmployees of the Subcontractor to disclose the following information:
(i) Identifying information that shall include the name, address, date of birth, and would only need to disclose board members if a board member meets Social Security Number of any Managing Employee of the definition of a Managing EmployeeContractor.
Appears in 1 contract
Samples: Contract
Disclosure Information. (A) Using the Department-specified disclosure form’s Managed Care Entity Disclosure Form, and in accordance with 42 CFR 455.104, the Contractor, if organized as a corporation, Contractor shall provide disclosures for each require the following disclosures:
(1) Each Person with an Ownership or Control Interest in the Contractor.
(B) The disclosures for Persons with an Ownership or Control Interest Contractor shall includedisclose:
(1i) Identifying information that shall include the person’s name and address of any Person (individual or corporation) with an Ownership or Control Interest in the Contractor. The address for corporate entities must include as applicable primary business name, address, every business location and the P.O. Box address;
(2) date of birth and birth, Social Security Number (in the case of an individual);
(3) or other tax identification number (in the case of a corporation). An individual shall disclose the address of his or her primary residence. A corporate entity shall include (as applicable) with an ownership or control interest in the Contractor or in any Subcontractor in which the Contractor has a five percent or more interest;primary business address, every business location and P.O. Boxes; and
(4ii) whether the Whether that person is related to another Person (individual or corporation) with an Ownership or Control Interest in the Contractor is related to another Person with an Ownership or Control Interest in the Contractor as a spouse, parent, child, or sibling;.
(52) whether the Each Person (individual or corporation) with an Ownership or Control Interest in any a Subcontractor in which the Contractor has a five percent or more interest shall disclose:
(i) Identifying information that shall include the person’s name, address, date of birth, Social Security Number (in the case of an individual) or other tax identification number (in the case of a corporation). An individual shall disclose the address of his or her primary residence. A corporate entity shall include (as applicable) the primary business address, every business location and P.O. Boxes; and
(ii) Whether that person is related to another person Person with an Ownership or Control Interest in the Contractor as a spouse, parent, child, or sibling; and
(6) the name of any Other Disclosing Entity (or Fiscal Agent or Managed Care Entity) in which an owner of the Contractor has an ownership or control interest.
(C3) Using the Department-specified form, and in accordance with 42 CFR 455.104, the Contractor shall provide disclosures of Managing Employees shall disclose:
(i) Identifying information that shall include the name, address, date of birth, and Social Security Number of any Managing Employee of the Contractor.
(D4) Government-owned Entities - If Persons with an Ownership Interest in the Contractor shall disclose:
(i) Identifying information that shall include the name of the individual; and
(ii) the name of any Other Disclosing Entity (or Fiscal Agent or Managed Care Entity) in which the person with an Ownership Interest in the Contractor is government-ownedalso a Person with an Ownership or Control Interest in the Other Disclosing Entity (or Fiscal Agent or Managed Care Entity).
(5) In the event that the Contractor Subcontracts with an entity to perform administrative functions for the Contractor’s Medicaid program, the Contractor shall require Persons with an Ownership or Control Interest in the Subcontractor to disclose anyone meeting the definition following information:
(i) Identifying information that shall include the person’s name, address, date of birth, Social Security Number (in the case of an individual) or other tax identification number (in the case of a corporation). An individual shall disclose the address of his or her primary residence. A corporate entity shall include (as applicable) the primary business address, every business location and P.O. Boxes; and
(ii) Whether that person is related to another Person with an Ownership or Control Interest in the Contractor is related to another Person with an Ownership or Control Interest in the Contractor as a spouse, parent, child, or sibling.
(6) In the event that the Contractor Subcontracts with an entity to perform administrative functions, for the Contractor’s Medicaid program, the Contractor shall require Managing EmployeeEmployees of the Subcontractor to disclose the following information:
(i) Identifying information that shall include the name, address, date of birth, and would only need to disclose board members if a board member meets Social Security Number of any Managing Employee of the definition of a Managing EmployeeContractor.
Appears in 1 contract
Samples: Prepaid Mental Health Plan Contract
