Disclosure Of Ownership And Control Interest Statement {CMS-1513} | Pdf Fpdf Doc Docx | Official Federal Forms

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Disclosure Of Ownership And Control Interest Statement {CMS-1513} | Pdf Fpdf Doc Docx | Official Federal Forms

Disclosure Of Ownership And Control Interest Statement {CMS-1513}

This is a Official Federal Forms form that can be used for Centers For Medicare And Medicaid Services.

Alternate TextLast updated: 5/2/2006

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DEPARTMENT OF HEALTH AND HUMAN SERVICES Form ApprovedCENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0086 INSTRUCTIONS FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT (CMS-1513) Completion and submission of this form is a condition of participation, certification, or recertification under any of the programs established by titles V,XVIII, XIX, and XX, or as a condition of approval or renewal of a contractor agreement between the disclosing entity and the Secretary of appropriateState agency under any of the above-titled programs, a full and accurate disclosure of ownership and financial interest is required.Failure to submitrequested information may result in a refusal by the Secretary or appropriate State agency to enter into an agreement or contract with any suchinstitution or in termination of existing agreements. SPECIAL INSTRUCTIONS FOR TITLE XX PROVIDERS All title XX providers must complete part II (a) and (b) of this form.Only those title XX providers rendering medical, remedial, or health related home-maker services must complete parts II and III.Title V providers must complete parts II and Ill. General Instructions For definitions, procedures and requirements, refer to the appropriate Controlling interest is defined as the operational direction or Regulations: management of a disclosing entity which may be maintained by any or all of the following devices:the ability or authority, expressed orTitle V 42CFR 51a.144 Title XVIII 42CFR 420.200 206 reserved, to amend or change the corporate identity (i.e., joint venture agreement, unincorporated business status) of the disclosing entity;theTitle XIX 42CFR 455.100 106 ability or authority to nominate or name members of the Board ofTitle XX 45CFR 228.72 73 Directors or Trustees of the disclosing entity;the ability or authority, expressed or reserved, to amend or change the by-laws, constitution,Please answer all questions as of the current date. If the yes block for any item is checked, list requested additional information under the or other operating or management direction of the disclosing entity;theRemarks section on page 2, referencing the item number to be right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution of that entity;the ability orcontinued.If additional space is needed use an attached sheet. authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortage or other Return the original and second and third copies to the State agency;retain the first copy for your files. indebtedness, to dissolve the entity, or to arrange for the sale or transfer of the disclosing entity to new ownership or control.This form is to be completed annually. Any substantial delay in completing the form should be reported to the State survey agency. Items IV VII - Changes in Provider Status Change in provider status is defined as any change in management DETAILED INSTRUCTIONS control.Examples of such changes would include:a change in Medical or Nursing Director, a new Administrator, contracting the operation ofThese instructions are designed to clarify certain questions on the form. Instructions are listed in question order for easy reference. No the facility to a management corporation, a change in the composition of the owning partnership which under applicable State law is notinstructions have been given for questions considered self-explanatory. considered a change in ownership, or the hiring or dismissing of anyIT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE employees with 5 percent or more financial interest in the facility or in an owning corporation, or any change of ownership. ANSWERED ACCURATELY AND THAT ALL INFORMATION BE CURRENT. For Items IV VII, if the yes box is checked, list additional information requested under Remarks. Clearly identify which item is being continued.Item I (a) Under identifying information specify in what capacity the entity is doing business as (DBA), example, name of Item IV- (a & b) If there has been a change in ownership within the trade or corporation. last year or if you anticipate a change, indicate the date in the (b) For Regional Office Use Only.If the yes box is checked for appropriate space. item VII, the Regional Office will enter the 5-digit number assigned by CMS to chain organizations. Item V - If the answer is yes, list name of the management firm and employer identification number (EIN), or the name of the leasingItem II- Self-explanatory. organization.A management company is defined as any organization that operates and manages a business on behalf of the owner of thatItem III- List the names of all individuals and organizations having business, with the owner retaining ultimate legal responsibility fordirect or indirect ownership interests, or controlling interest separatelyoperation of the facility. or in combination amounting to an ownership interest of 5 percent or more in the disclosing entity. Item VI- If the answer is yes, identify which has changed (Administrator, Medical Director, or Director of Nursing) and the dateDirect ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity. A the change was made. Be sure to include name of the newdisclosing entity is defined as a Medicare provider or supplier, or otherAdministrator, Director of Nursing or Medical Director, as appropriate.entity that furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health program, or health related Item VII- A chain affiliate is any free-standing health care facility that is either owned, controlled, or operated under lease or contract by anservices under the social services program. organization consisting of two or more free-standing health careIndirect ownership interest is defined as ownership interest in an entityfacilities organized within or across State lines which is under thethat has direct or indirect ownership interest in the disclosing entity.ownership or through any other device, control and direction of aThe amount of indirect ownership in the disclosing entity that is held by common party. Chain affiliates include such facilities whether public,any other entity is determined by multiplying the percentage of private, charitable or proprietary. They also include subsidiaryownership interest at each level.An indirect ownershi

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