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Provider Enrollment Information
 
Reporting Ownership Information

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

  • 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
    • Owns an 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 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.

Note: If a provider submits the required ownership information at enrollment or revalidation but undergoes a change in ownership, he or she is required to submit a change in ownership notification within 35 days 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

If a provider organization does not have an owner or a person with a controlling interest of five percent or more, "No Individual Owners" should be entered in the Name field on the Owner/Controlling Interest in Applicant — Detail panel, and filler information should be entered in the other required fields so that the panel can be bypassed. All appropriate individuals must be entered on the Managing Employee panel instead.

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

 
 
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