Provider Disclosure of Ownership and Control
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UPMC Health Plan, on behalf of itself and its affiliates, is required to collect disclosure of ownership, control interest, and management information from providers that participate in UPMC Health Plan’s networks. Failure to submit the requested information may result in an inability to enter into a provider contract or termination of existing provider contracts.
FAQ - Provider Disclosure of Ownership and Control (PDF)
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Information to Gather Before Filling out the Disclosure of Ownership and Control (PDF)
FOR YOUR SECURITY, THIS FORM CAN NOT BE SAVED AND MUST BE COMPLETED IN ONE ATTEMPT. This form typically takes 30–60 minutes to complete in one sitting. Thank you for your cooperation with our efforts to comply with federal regulations.
* Required Information
Please list the requested information regarding the Disclosing Entity.
The Disclosing Entity is the facility, provider group, or individual provider that is completing this form and has or is applying for a participating provider agreement with UPMC Health Plan for participation in UPMC Health Plan provider networks.
The information provided below should reflect that of the entity or individual that has a contract or is applying for a contract with UPMC Health Plan, and the tax ID (SSN/TIN) associated with that contract or application.
Please list the required information for all individuals or organizations with a 5-percent or more Ownership or Control Interest in the Disclosing Entity. Ownership or Control Interests may be direct or indirect. Please see the Provider Disclosure Statement Definitions for additional details. The address listed for corporate entities must be the primary business address. For individuals, the address listed must be the primary home address. Providing the SSN and/or TIN (as applicable) is required under 42 CFR § 455.104. Any form without the required SSN or TIN is incomplete and will not be processed.
Disclosing Entities must report whether any of the persons listed in sections I or II of this form are the spouse/partner, parent, child, or sibling of any other person listed.
Please list any individuals identified in sections I or II of this form who are a spouse/partner, parent, child, or sibling of any other individual so identified.
Please provide Person 1
Please provide Person 2
Please provide Person 2, Same person is selected for Person 1 and Person 2
Please provide Relationship
A Disclosing Entity must report whether any of the individuals or entities listed in sections I or II of this form have an Ownership or Control Interest of 5 percent or more in any other Disclosing Entity that is participating in UPMC Health Plan’s networks.
Please list any such individuals or entities, along with the name and TIN of the other Disclosing Entity that is participating in UPMC Health Plan’s networks in which they have an Ownership or Control Interest.
Please provide Individual or Entity*
Please list the required information for all officers and directors of the Disclosing Entity. If the Disclosing Entity is a not-for-profit organization, please list the required information for all board members.
Please list the individual’s primary home address. Providing the SSN is required under 42 CFR § 455.104. Any form without the required SSN is incomplete and will not be processed.
List all Managing Employees and/or Agents including their names, DOBs, addresses, SSNs, and titles.
A Subcontractor is an individual, agency, or organization to which the Disclosing Entity has contracted or delegated some of its management functions or responsibility to provide medical care to patients. Examples of Subcontractors include, but are not limited to, DME providers, billing agencies, and radiology services. An employee of the Disclosing Entity is not a Subcontractor.
Please complete the following for any Subcontractor in which the Disclosing Entity has at least a 5-percent direct or indirect Ownership or Control Interest.
Please provide First Name
Please provide Last Name
Please provide Title
Please provide Phone Number*
Please provide Fax Number*
Please provide Email*
Please provide Date*
Please Attest
- All information provided herein is true, accurate, and complete.
- Any individuals or organizations providing medical services on behalf of the Disclosing Entity are screened with all applicable background checks, including, but not limited to, verification against the HHS Office of Inspector General List of Excluded Individuals/Entities and any applicable state, federal, or other governmental exclusion or sanction databases.
- Additions or revisions to the information included herein will be submitted immediately upon revision.
- I have authority to execute this attestation on behalf of the Disclosing Entity.
- I have authority to release all personal information included herein.
- I understand that misleading, inaccurate, or incomplete data may result in corrective action, up to and including termination of the Disclosing Entity’s provider contract with UPMC Health Plan.
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