wisconsin.gov HomeState AgenciesSubject DirectoryDepartment of Health Services
Welcome  » October 17, 2019 8:38 PM
Login
Search
Alerts
  • Business Objects will not be available to users from 4 p.m. on Thursday, October 17, through 6 a.m. on Monday, October 21 and from 4 p.m. on Thursday, October 31, through 6 a.m. on Monday, November 4 for maintenance.
 
Provider Enrollment Information
 
Reporting Ownership Information
ForwardHealth Requires Ownership Information

At the time of provider enrollment and revalidation, ForwardHealth collects personal information about:

  • All persons with an ownership or controlling interest. This includes a person or corporation for which one or more of the following applies:
    • Has an ownership interest totaling five percent or more in a disclosing entity
    • Has an indirect ownership interest equal to five percent or more in a disclosing entity
    • Has a combination of direct and indirect ownership interest equal to five percent or more in a disclosing entity
    • Has an ownership interest of five percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least five percent of the value of the property or asset of the disclosing entity
    • Is an officer or a director of a disclosing entity that is organized as a corporation
    • Is a person in a disclosing entity that is organized as a partnership
  • Agents. An agent is any person who has been delegated the authority to obligate or act on behalf of a provider.
  • Managing employees. A managing employee is a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.

ForwardHealth will only use the provided information for provider enrollment and revalidation. All information provided will be protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy rule.

Providers Are Required to Report Changes in Ownership Within 35 Days

If a provider submits the required ownership information at enrollment or revalidation but undergoes a change in ownership, they are required to submit a change in ownership notification within 35 calendar days after the effective date of the change and complete a new enrollment application.

Information to Be Submitted for an Individual Owner With a Controlling Interest

Providers are required to submit the following information for each individual owner with a controlling interest in the provider:

  • First and last name
  • Owner's Social Security number (SSN)
  • Date of birth
  • Street address, city, state, and zip+4 code
Information to Be Submitted for an Organizational Owner With a Controlling Interest

Providers are required to submit the following information for each organizational owner with a controlling interest in the provider:

  • Legal business name
  • Tax ID number
  • Business street address, city, state, zip+4 code
Information to Be Submitted for an Agent or Managing Employee

Providers are required to submit the following information for each managing employee and agent:

  • First and last name
  • Managing employee's and agent's SSN
  • Date of birth
  • Street address, city, state, and zip+4 code
 
 
About  |  Contact |  Disclaimer  |  Privacy Notice
Wisconsin Department of Health Services
Production PROD_WIPortal2_M713B__5
Browser Tab ID: 1   -1