Form

In accordance with TITLE 42 -- PUBLIC HEALTH, subpart B - disclosure of information by providers and fiscal agents, 42 CFR 455.100, please complete and provide all applicable information requested herein. Upon completion and prior to submission, you will be required to attest to the information that you are providing and provide your agreement to the last two statements regarding lobbying. Completion of this disclosure and your agreement is required for participation in the Healthfirst provider networks.

Section 1:

Select the value from this dropdown to confirm this disclosure

Entity Name:

FEIN:

NPI (if not applicable, enter "N/A"):

Ownership in Applicant (per 42 CFR, Part 455.104(b)(1)(i) - (Entities and/or Individuals)

Name of Individual or Entity:

Title:

Date of Birth:

Address (Home Address if Individual; Primary Address if Corporation) - Street:

City:

Zip Code (5 digit):

State:

Email Address:

TIN:

FEIN:

% of Ownership(if none, put 0):

NPI (if not applicable, enter "N/A"):

For Individuals Only:

If you are related to another person with an ownership or control interest in the Applicant, complete the following:

Name of other Owner:

Relationship to other Owner:

FOR CORPORATIONS ONLY:

Use the space below to report other business addresses (per 42CFR, Part 455.104(b)(1)(i)):

Section 2:

Ownership in Other Disclosing Entities (ODE) (per 42 CFR, Part 455.104(b)(3)) - (Complete if any identified in Section 1 has an ownership or control interest in ODE)

Name (from Section 1):

Name of ODE:

NPI or Medicaid ID of ODE:

Section 3:

Ownership in Subcontractors If the Applicant has an ownership or control interest of 5% or more in a subcontractor and an Owner of the Applicant also has an ownership or control interest in the subcontractor, complete the boxes below. If those identified in this Section have a familial relationship with a person with ownership or control interest in one of these subcontractors, complete Section 4).

Owners Name (from Section 1):

Subcontractor Name:

Tax Identification Number:

Section 4:

Familial Relationship in Subcontractors (Complete if those identified in Section 3 have a *familial relationship with a person with ownership or control interest in one of the subcontractors identified in Section 3). *parent, child, sibling, spouse

Owners Name:

Subcontractor Name:

Tax Identification Number:

Section 5:

Managing Employees & Those with a Control Interest - Including, but not necessarily limited to, the following: Facility Administrator, all Members of the Board of Directors, Managing Employees, Compliance Officer, Laboratory Director, Supervising Pharmacist. Include familial relationship to the Applicant (spouse, parent, child, sibling), if any.

Name:

Title (see instructions):

Home Address:

City:

Zip Code (5 digit):

State:

SSN/TIN:

Date of Birth:

Familial Relationship:

Section 6:

Respond to this question on behalf of:

the Applicant
all individuals and entities identified in Sections 1 & 5
any entity in which the Applicant has a 5% or more ownership

Have any of the individuals/entities (1, 2 and 3) ever been convicted of a crime related to the furnishing of, or billing for, medical care or supplies or which is considered an offense involving theft or fraud or an offense against public administration or against public health and morals in any State?

Yes

NOTE: If you answered "Yes" to the question above, you must complete the section below.

Name:

Address:

Zip Code (5 digit):

State:

Section 7:

1. No Federal appropriated funds have been paid or will be paid to any person by or on behalf of the Contractor for the purpose of influencing, or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of a Member of Congress in connection with the award of any Federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federal' appropriated funds have been paid or will be paid to any person for the purpose of influencing or attempting to influence an officer or employee of any agency, a Member of Congress in connection with the award of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any, cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement, and the Agreement exceeds $100,000, the Contractor shall complete and submit Standard Form LLL "Disclosure Form to Report Lobbying," in accordance with itsinstructions.

I acknowledge that I have read, fully understand, and agree to the statements above. I also agree that all information provided, to the best of my knowledge, is true and accurate.

Signature:

Date: