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)
Before you begin, be sure you have access to all the information you need to complete the form.
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 provide Disclosing Entity
Please only select Sole Owner if you do not have a Tax ID Number.
Does the Disclosing Entity have any organizations or individuals with a 5-percent or more Ownership or Control Interest?
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 provide an answer to Does the Disclosing Entity have any familial relationships to disclose?
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 provide an answer to Is the Disclosing Entity aware of any of the individuals or entities listed in sections I or II of this form having 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 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 provide an answer to Does the Disclosing Entity have any officers, directors or board members?
Please provide an answer to Does the Disclosing Entity have any Managing Employees or Agents to disclose?
Managing Employee: A general manager, business manager, administrator, or other individual who exercises operational or managerial control over or directly or indirectly conducts the day-to-day operations of the Disclosing Entity. See the definition in 42 CFR § 455.101.
Agent: Any person (other than a director, officer, board member, or managing employee) who has been delegated the authority to obligate or act on behalf of the Disclosing Entity. . For example, Agents include people who have the authority to enter into contracts or sign checks on behalf of the Disclosing Entity. This is not intended to include every employee of the Disclosing Entity. See the definition in 42 CFR § 455.101.
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 provide an answer to Does the Disclosing Entity have any Subcontractors?
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*
- 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.