NORTH COUNTRY COMMUNITY MENTAL HEALTH

PROVIDER DISCLOSURE INFORMATION

North Country Community Mental Health agrees to use this information only for verification that the parties listed hereon are not excluded providers and consequently ineligible for participation in Medicare, Medicaid and other Federal health care programs.

  1. Fill in the name of the PERSON(s)or BUSINESS ENTITYthat receives payment for the items orservices you provideto North Country CMH. Please complete the missing ID#, Social Security # or Date of Birth, as applicable.
  • If payments are made to a BUSINESS ENTITY, complete the remainder of this Form.
  • If payments are made to a PERSON, skip to the bottom of page two and sign the Form.

PERSON or BUSINESS ENTITY / Employer ID#
(Required for business entities only) / Social Security #
(Optional - used for exclusionary purposes only) / Date of Birth
(Required)

2. If payments are made to a BUSINESS ENTITY (a company, a partnership, etc.) and NOT to a PERSON, please complete the following information (use reverse side for additional names):

  1. Names of subsidiaries in which the BUSINESS ENTITY has direct or indirect ownership of 5% or more

Subsidiary Name
  1. Direct or indirect individual owners who own 5% or more of the BUSINESS ENTITY, orof any subsidiary noted above:

Individual Name and Address / Relationship to Other Individuals Named Here / Social Security #
(Optional - used for exclusionary purposes only) / Date of Birth
(Required)

C.Other entities in which any individual noted above holds a direct or indirect interest of 5% or more:

Entity Name

D.All managing employees of the BUSINESS ENTITY, and their respective title (such as a general manager, business manager, administrator, or director) who exercise operational or managerial control over the BUSINESS ENTITY, or who directly or indirectly conduct the day-to-day operations of the BUSINESS ENTITY (use reverse side for additional names):

Individual Name / Title / Social Security #
(Optional - used for exclusionary purposes only) / Date of Birth
(Required)

E.Please disclose below whether any individual noted above has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid or the Title XX services program.

Individual Name and Offense

I certify that this information is accurate to the best of my knowledge and belief.

By: ______Date: ______

Printed Name: ______

Rev 02/12