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Integrated Health Management Solution Owners And Boards Provider Maintenance Form MIHMS_MF_0006 - Maine
| Integrated Health Management Solution Owners And Boards Provider Maintenance Form Form. This is a Maine form and can be used in Department Of Health Statewide . |
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Maine Integrated Health Management Solution Provider Maintenance Form (MIHMS_MF_0006) MAINE INTEGRATED HEALTH MANAGEMENT SOLUTION OWNERS & BOARDS PROVIDER MAINTENANCE FORM (MIHMS_MF_0006) The purpose of this form is to make modifications to a paper enrollment application. This form is to update any information regarding owners and board members. Complete this form if you need to do any of the following: Add one or more new owners or board members Remove one or more existing owners or board members Update the information on file for one or more existing owners or board members If modifications need to be made to service location(s) refer to Maine Integrated Health Management Solution SERVICE LOCATIONS Provider Maintenance Form MIHMS_MF_0007. If modifications need to be made to rendering provider(s) refer to Maine Integrated Health Management Solution RENDERING PROVIDERS Provider Maintenance Form MIHMS_MF_0008. Please print or type all information so that it is legible. Use only blue or black ink. Do not use pencil. Failure to provide accurate, complete information could result in delayed processing of your application and/or incorrect claim reimbursement. Note that an asterisk (*) following a question or field label in this form indicates required information. If you are not changing ownership or board member information for your enrollment or have otherwise received this form in error, contact the MaineCare Provider Enrollment Unit at 1-866-690-5585. SECTION 1. IDENTIFYING INFORMATION 1. What is your NPI or API? * ___________________________________________________ 2. What is your tax ID? * Note: Supply at least one of the following numbers. You may provide both. FEIN ____________________________________ 3. Name * Note: For individuals, supply the name in this field in the format LastName, FirstName. For groups, supply the name in this field in the format Group Name. For facilities, agencies, or organizations, supply the name in this field in the format FAO Name. Ensure the name is spelled correctly. ______________________________________________________________________________________________ SSN ____________________________________ Last updated: 07/21/2011 An asterisk (*) indicates a required field. MIHMS_MF_0006_Ownership_Boards_V5.0_20110721 Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Maine Integrated Health Management Solution Provider Maintenance Form (MIHMS_MF_0006) SECTION 2. OWNERS AND BOARD MEMBERS Part A. General Information In accordance with Form CMS-1513 (Disclosure of Ownership and Control Interest Statement), you must provide the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination amounting to an ownership interest of five percent (5%) or more in the disclosing entity. If you are maintaining owner or board member information for multiple owners or board members, you must provide a copy of this Section (pages 2-7) for each owner or board member. Unless otherwise indicated, all fields in all parts are required. All fields except FEIN, End Date, and Address 2 are required when supplying information about a person who is an owner or a board member. All fields except End Date and Address 2 are required when supplying information about an organization that is an owner. FEIN is required when providing information about an organization. 1. Are you adding, removing (or terming out), or updating information for an owner or board member? Adding an owner or board member Removing (or terming out) an existing owner or board member Updating information for an existing owner or board member 2. Does the following information apply to an owner or a board member? * Owner Board member 3. Name, Tenure, and Address Information First and Last Name * FEIN or SSN * Begin Date * End Date Address 1 * Address 2 ZIP or Postal Code * City * County * State or Province * Country * _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Has this person ever been sanctioned, excluded, or convicted of a criminal offense related to Medicare, Medicaid, or any federal agency or program (42 CFR 45)? * Sanctioned Last updated: 07/21/2011 An asterisk (*) indicates a required field. Excluded Convicted None of these MIHMS_MF_0006_Ownership_Boards_V5.0_20110721 Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Maine Integrated Health Management Solution Provider Maintenance Form (MIHMS_MF_0006) Part B. Owner Relationships 1. If there are owners who are related to each other (as spouses, parents and children, or siblings), you must share those relationships in the table below. * If there are related owners, specify two different owners' names and their relationship. Any relationships you specify will read from left to right, such as "Bob Smith is parent of Joe Smith." If you need additional space for this list, you may attach a separate page. For the attached page, label it at the top margin with Section 2, Part B, #1--Owner Relationships Owner Name Relationship (spouse, parent/child, sibling) Owner Name ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ________________________________________________________________________________________
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