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Provider Disclosure of Ownership/Control Interest, Managing Employees & Criminal Convictions

The State of Michigan (as a state agency managing a federal program) requires HealthPlus to obtain the following information from its contracted providers. Information will be requested at the time of credentialing/contracting and on a three-year cycle.

As required by federal regulations, providers must disclose the following information:

  • Individuals with Ownership and Control Interest
  • Managing Employee Information
  • Criminal Convictions of the Provider and Other Parties Associated with the Provider's entity
HealthPlus will utilize this information only for the purpose of complying with the requirements of the State of Michigan in conducting criminal and other background checks and will comply with all federal and state privacy & security rules and regulations.

Questions regarding this form may be directed to your HealthPlus Provider Network or Pharmacy Department representative.
Provider Information
Provider Name:
Address:
City:
State:
Zip Code:
Provider Telephone:
Example: 555-555-1234
Provider Email Address:
Example: John.doe@somecompany.com
1) Ownership & Control Disclosure
Please list below all individuals with 5% or more ownership or control interest in your entity. (42CFR §455.104):
 Check if you have no Ownership/Control Interest Disclosures to report
No Owner/Control Interest Disclosure Records Entered
Add Ownership/Control Disclosure Record:
Complete ALL fields below and click 'Add'
First Name Middle Name Last Name SSN # Address City State Zip Code
2) Managing Employee Disclosure
Please list managing employee(s)*. (42CFR §455.101):
 Check if you have no Managing Employee Disclosures to report
No Managing Employee Disclosure Records Entered
Add Managing Employee Disclosure Record:
Complete ALL fields below and click 'Add'
First Name Middle Name Last Name SSN # Address City State Zip Code
3) Criminal Convictions Disclosures
Has any person who has ownership or control interest in the provider, or entity, or is an agent or managing employee of the provider, ever been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid or the Title XX services program since the inception of those programs? (42CFR §455.106):
 Check if you have no Criminal Conviction Disclosures to report
No Criminal Conviction Disclosure Records Entered
Add Criminal Conviction Disclosure Record:
Complete ALL fields below and click 'Add'
First Name Middle Name Last Name SSN # Address City State Zip Code
Attestation
I attest that the information provided is true and accurate to the best of my knowledge. I understand it is the provider's responsibility to notify HealthPlus of Michigan if there is a change in any information provided on this form (including name/address/staffing changes; criminal convictions; status, etc.).
Authorizing Provider Agent:
Date: