Thank you for your interest in joining the Provider Panel. Please fill out the application below.

Disclosure Statement

{{ALL}} {{IS/ARE}} required to collect disclosure of ownership, controlling interests, and management information from providers that are credentialed or otherwise enrolled to participate in the Medicaid program and/or the Pre-paid Inpatient Health Plan (PIHP). This requirements is pursuant to a Medicaid and/or PIHP State Contract with the State Agency and the federal regulations set forth in 42 CFR Part §455. Required information includes: 1) the identity of all owners and others with a controlling interest of 5% or greater; 2) certain business transactions as described in 42 CFR §455.105; 3) the identity of managers and others in a position of influence or authority; and 4) criminal convictions, sanctions, exclusions, debarment or termination information for the provider, owners or managers. The information required includes, but is not limited to, name, address, date of birth, social security number (SSN) and tax identification (TIN).

Completion and submission of this Statement is a condition of participating as a credentialed or enrolled provider in the {{ALL}} Provider Network for services to members under Medicaid Managed Specialty Supports and Services Concurrent 1915(b)(c) Wavier Program. Failure to submit the requests information may result in a refusal of participation in {{ALL}} Provider Network or denial of a claim.

This statement should be submitted at any of the following times: upon the submission of an application; upon execution of an agreement; during re-credentialing or re-contracting; within 35 days after any change in ownership of the disclosing entity. A Statement must be provided to {{ALL}} within 35 days of a request for information by the US Department of Health and Human Services (DHHS) or the State Agency. {{ALL}} maintains policies and practices that protect the confidentiality of personal information, including Social Security numbers, obtained from its providers and associates in the course of its regular business functions. {{ALL}} {{IS/ARE}} committed to protecting information about its providers and associates, especially the confidential nature of their personal information.

Provider/Provider Entity Information

Office #1 (list all Practice Locations)

Add Office

Section I: Individual Provider Ownership Information

Please list the information for each individual or organization that has a Direct or Indirect Ownership of 5% or more or has a Controlling Interest in your entity. If the Owner is a corporation: the primary business address must be listed and every business location and PO Box address. Provider members of a group practice who have ownership or a controlling interest in Provider Entity must submit a separate Statement.

Providing the SSN and TIN (as applicable) is under 42 CFR 455.104; please see Section 4313 of the Balanced Budget Act of 1997, amended Section 1124, and the Federal Register Vol. 76 No. 22. Any form without the SSN and TIN (as applicable) is incomplete and will not be processed.

View the glossary.

Section II: Ownership in Other Providers & Entities

Please identify the other providers or entities that are owned or controlled at least 5% by the same individual or organization identified in Section I that has an Ownership or Controlling Interest in your entity. This information is to identify shared and interconnected ownership and controlling interests.

View the glossary.

Section III: Subcontractor Ownership

If your entity has a Direct or Indirect Ownership of 5% or more in a Subcontractor and other individuals or entities also have a Direct or Indirect Ownership of that same Subcontractor, please identify the Subcontractor and provide the information for the additional owners.

View the glossary.

Section IV: Familial Relationships of All Owners

Report whether any of the persons listed in Sections I, II, and III are related to each other and identify the parties and their relationship. For the definition of domestic partner, refer to your state’s laws. Provider members of a group practice who are related to the Provider Entity’s owners or those with a controlling interest must submit a separate Statement.

*At any time during the Contract period, it is the responsibility of the Povider/Provider Entity to promptly provide notice upon learning of convictions, sanctions, exclusions, debarments and terminations (see Fed. Register, Vol. 44, No. 138)

View the glossary.

Section V: Criminal Convictions, Sanctions, Exclusions, Debarment, or Terminations

List your own criminal convictions, sanctions, exclusions, debarments, and termination, and for any person who has an ownership or controlling interest, or is an agent or managing employee of your entity. List all offenses related to each person’s or entity’s involvement in any program under Medicare, Medicaid, CHIP, or the Title XX services since the inception of these programs. Review all of the databases necessary to verify this information:

  1. Exclusion status may be verified through the HHS-OIG List of Excluded Individuals/Entities (LEIE).
  2. Sanction information is available in the GSA’s SAM (System for Award Management) database.
  3. State specific exclusions/sanction databases may be accessed through the State Agency’s website.

View the glossary.

Section VI: Business Transaction Information

  1. List the Ownership of any Subcontractors that you have had business transactions totaling more than $25,000 within the last twelve (12) month period ending on the date of the request.
  2. List any Significant Business Transactions between your entity and any Wholly Owned Supplier during the past 5 years.
  3. List any Significant Business Transactions between your entity and any Subcontractor during the past 5 years.

Remember that a Significant Business Transaction is defined as any transaction or series of related transactions that exceeds the lesser of $25,000 or 5% of a provider’s operating expenses during any one fiscal year.

This information must be made available within 35 days of a request by the US Department of Health and Human Services (HHS), the State Medicaid Agency, and the Medicaid Managed Care Organization responding to an HHS or State request.

View the glossary.

Section VII: Management & Control

  1. List the information for all employees that hold a position of Managing Employee within your entity.
  2. List the information for all Agents that have the authority to obligate or act on behalf of your entity.
  3. List the information for all individuals on the governing board or board of directors if your entity is organized as a corporation. CMS requires the identification of officers and directors of a Provider Entity that is organized as a corporation, without regard to the for-profit or not-for-profit status of that corporation.

View the glossary.

Through digital signature below, I hereby certify that any employees or contractors providing services pursuant to a contract with Community Mental Health for Central Michigan are screened with the applicable background check including, but not limited to, verification against the OIG’s List of Excluded Individuals & Entities and the System for Award Management (SAM) and any applicable state, federal or other governmental exclusion or sanction database and that the information provided herein is true, accurate and complete. Additions or revisions to the information above will be submitted immediately upon revision. Additionally, I understand that misleading, inaccurate, or incomplete data may result in a denial of a claim and/or termination of the contract.