Government of the District of Columbia
Department of Health Care Finance (DHCF)
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DME/POS)
Medicaid Provider Enrollment Package
APPLICATION PROCESS
Step One
New applicants and re-enrolling providers are required to first submit a completed application along with
requested documentation. A separate application is required for each service location at which the applicant
intends to provide DME/POS services. DHCF will review the application and make a determination within 30
business days as to whether the applicant can proceed to the next steps of the application process. Applicants
not successfully completing Step One will be notified in writing. Completion of Step One, by itself, does not
constitute acceptance into the Program.
Step Two
Applicants successfully completing Step One will be required to attend a mandatory provider orientation
(specific staff from the applying company must attend, as appropriate) and sign a Provider Agreement along
with accompanying documents.
Step Three
Applicants successfully completing Steps One and Two of the process will be notified of their acceptance or
re-enrollment into the Program. Once notified of acceptance, providers will be permitted to bill and receive
reimbursement for services rendered to District of Columbia Medicaid recipients.
IMPORTANT FACTS TO REMEMBER
• Submission of an application does not constitute automatic acceptance or re-enrollment into the program.
• Anticipated time for DHCF’s review of applications and determination of whether applicants can proceed to
orientation is approximately 30 business days.
• Applications will be rejected and returned to sender if any information is omitted, requested documentation is not
included, or the submitted package is not assembled as instructed.
• A National Provider Identifier (NPI) is mandatory. For information on the NPI, visit
https://nppes.coms.hhs.gov/NPPES/Welcome.do
• “In-State” DME/POS Providers are defined as entities whose service site is located inside the geographic
boundaries of the District of Columbia.
• “Out–of-State” DME/POS Providers are defined as entities whose service site is located outside the geographic
boundaries of the District of Columbia.
• A separate application is required for each location at which the applicant intends to provide DME/POS services.
• Complete each section of the application, if applicable. Do not remove any pages from the application package.
• Electronic copies of the “DME/POS Provider Enrollment Package” can be found on the District of Columbia
Direct questions to:
District of Columbia Fiscal Agent
Affiliated Computer Services, Inc. (ACS) – Enrollment Division
8 A.M. to 5 P.M. EST, Monday through Friday
202-906-8318 (inside the District of Columbia)
1-866-752-9231 (outside the District of Columbia)
Mail completed application package to:
Provider Enrollment
Affiliated Computer Services, Inc. (ACS) – Provider Enrollment
P.O. Box 34761
GOVERNMENT OF THE DISTRICT OF COLUMBIA
Department of Health Care Finance (DHCF)
DURABLE MEDICAL EQUIPMENT, PROSTHETIC, ORTHOTICS AND MEDICAL SUPPLIES
(DME/POS) PROVIDER APPLICATION PACKAGE
Important:
• Read all instructions before completing the application.
• Type or print clearly, in ink.
• If you make corrections, please line through, date, and initial in ink.
• Return the completed application package and accompanying documentation in the format
specified to:
ACS Provider Enrollment
P.O. Box 34761
Washington, DC 20043-4761
DISTRICT OF COLUMBIA DME/POS MEDICAID PROVIDER APPLICATION
FOR
(Insert the full legal name of your company)
Washington, DC 20043-4761
Do not use staples on this application or on any attachments. Do not leave any questions, boxes or lines blank. Enter N/A if not applicable.
New provider
National Provider Identifier (NPI): _____ _____ Medicare Provider Number: _______________________________
For any of the following actions, include current or previous D.C. Medicaid provider number: _________________________ Re-Enrollment (required every three (3) years)
Change/Update (state the type of change/update and the effective date below).
_____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________
Section
1
ENROLLMENT
ACTION
Directions:
•
Check (√) ALL that apply.
•
A National Provider Identifier (NPI) is mandatory for all new applicants and re-enrolling providers.
•
A Medicare Provider Number is required for all applicants.
•
If re-enrolling as a Medicaid provider, provide your DC Medicaid provider number.
•
If changing/ updating information, indicate the type of change requested and the effective date of the change.
•
ATTACH THE FOLLOWING DOCUMENTS BEHIND THIS PAGE (if applicable):
o
Copy of your NPI letter
o
CMS Medicare Supplier letter
The National Provider Identifier (NPI) final rule, Federal Register 45CFR Part 162, was published
on January 23, 2004 by the Department of Health and Human Services (DHHS) as part of the
Health Insurance Portability and Accountability Act (HIPAA). The rule established the NPI as the
standard unique identifier for health care providers to be used in HIPAA-covered transactions. The
rule requires covered health care providers, clearinghouses, and health plans to use this identifier
in HIPAA-covered transactions.
All DC Medicaid healthcare providers must provide DHCF with their NPI information. Please
complete the below information and return with your Medicaid Provider Enrollment Application. If
you do not have an NPI yet, you may obtain one at
https://nppes.cms.hhs.gov/NPPES/Welcome.do
. If you do not meet the definition of ‘healthcare
provider’ as defined under HIPAA, this form is not required.
If you are a healthcare provider please provide your NPI that was issued by National Plan &
Provider Enumeration System (NPPES) in the space below. Please also provide your taxonomy
code that is currently on file with NPPES.
NPI
Taxonomy Code
X
If this application is for an organization, please supply additional NPIs and taxonomy codes on a
separate sheet.
I certify this information to be true and accurate.
_______________________________ ________________________
_________
Provider Signature or Authorized Representative Printed Name DateSection
2
BUSINESS/CORPORATE
Directions:
•
Check one box only.
•
If “Other” is checked, write in type of entity.
•
ATTACH THE FOLLOWING DOCUMENTS BEHIND THIS PAGE:
o
Business License
o
Certificate of Occupancy
o
Applicable Permits
o
Legible copy of the partnership agreement (if “Partnership” is checked)
TYPE OF ENTITY (check one)
Sole proprietor Partnership (attach legible copy of agreement) Government Entity
Corporation: Limited Liability Company (LLC): Nonprofit Corporation
Other: _____________________________________ State Registered/Filed: ______________________________________
Section
3
APPLICANT/PROVIDER
Directions:
•
3a) Company Name
o
Provide company name or corporate name as registered with the Internal Revenue Service (IRS)
and under which business is conducted.
o
Provide primary business location address, telephone and fax numbers, website and email address.
•
3b) Out-of-State Applicants ONLY
o
Providers located outside the District of Columbia must have a registered agent, be enrolled as a
Medicaid provider in state where your business is principally located, and be registered in the
District of Columbia to conduct business.
o
Provide information regarding your District of Columbia registered agent.
o
PO Boxes are prohibited
•
ATTACH THE FOLLOWING DOCUMENTS BEHIND THIS PAGE (if applicable):
o
D.C. Certificate of Authority [Corporation] or D.C. Certificate of Registration [LLC]
(Out-of-State providers ONLY)
o
Proof of Medicaid enrollment in your state (Out-of-State providers ONLY)
o
Description of ownership and a list of major owners (stockholders owning or controlling
five (5) percent or more outstanding shares)
o
List of Board Members and their affiliations
o
Copy of the basic organizational documents of the provider, a roster of key personnel
with titles, including an organizational chart
3a) Company Name, as listed with the IRS. (Note: Name indentified below should match name indentified on the IRS form included in this application package.)
Name of Owner(s) _______________________________________________________________________________ Doing Business as ________________________________________________________________________________ Business Address __________________________________________________________________________ City/State/Zip ___________________________________________________________________________________ Telephone _________________________________________ Fax ________________________________________ Website ________________________________________ Email _______________________________________________ 3b) Out-of-State applications ONLY
1. Registered Agent (PO Box Prohibited):
Name (Last, First, Middle) ___________________________________________________
Company Name____________________________________________________________
Address__________________________________________________________________ City/State/Zip______________________________________________________________
Telephone________________________________ Email____________________________
Website___________________________________________________________________
2. Medicaid Provider Number in the state where your business is principally located ____________________________________ (Attach copy proof of Medicaid enrollment in your State)
Section 4
PROOF OF LIABILITY INSURANCE
Directions:
•
Minimum coverage is $300,000.
•
ATTACH THE FOLLOWING DOCUMENT BEHIND THIS PAGE:
o
Copy of the Certificate of Insurance for the business address listed on this application
Name of Insurance Company ______________________________________________________________________________________ ______________________________________________________________________________________________________________
Insurance Policy Number Date Policy issued (mm/dd/yyyy) Expiration Date of Policy (mm/dd/yyyy)
______________________________________________________________________________________________________________ Insurance Agent’s Name (Last, First, MI)
______________________________________________________________________________________________________________
Section
5
BACKGROUND
CHECKS
Directions:
•
In 5a, state whether or not any personnel providing services at this service site do now or will:
1) enter beneficiaries’ homes to deliver DME/POS products, to fit DME/POS products to patients, or for other
purposes; or
2) have physical contact with beneficiaries to ensure the correct fit or teach appropriate use of prosthetics,
wheelchairs, or other DME/POS equipment; or have any other physical contact with patients beyond that physical
contact routinely made by a cashier or other personnel performing administrative activities.
•
In 5b, list every person in your company at this service location who will have contact with DC Medicaid
recipients in any of the ways described above. For each such person:
o
If he or she holds a current professional license as a health care provider, attach a copy of the license.
o
If he or she does not currently possess a valid license as a health care provider, provide evidence of a
background check.
If additional space is needed, attach separate sheet(s) of paper behind the next page.
•
FOR EVERY PERSON LISTED IN 5b, ATTACH THE FOLLOWING DOCUMENTS BEHIND 5b:
o
Copies of the professional license(s) of all personnel who are licensed as a health care provider and who
have or will have physical contact with beneficiaries (as described above); and
o
Copies of current (within the past 90 days) criminal background checks for each person who has or will
have physical contact with beneficiaries as described above, and who does not currently have a valid
professional license as a health care provider.
5a) Declaration of whether personnel have physical contact with beneficiaries. Please answer YES or NO to the following questions:
Do (or will) any personnel providing services at this service site:
1) enter beneficiaries’ homes to deliver DME/POS products, to fit DME/POS products to patients, or for other purposes? YES _______ NO _________
2) have physical contact with beneficiaries to ensure the correct fit or teach appropriate use of prosthetics, wheelchairs, or other DME/POS equipment; or have any other physical contact with patients beyond that physical contact routinely made by a cashier or other personnel performing administrative activities.
YES _______ NO _________
If you answered “YES” to either of the above two questions, go to 5b.
5b) List of personnel with physical contact with beneficiaries.
On the next page(s), list every person in your company at this service location who will have contact with DC Medicaid recipients in any of the ways described above. For each such person:
o If he or she holds a current professional license as a health care provider, provide a copy of the license.
o If he or she does not currently possess a valid license as a health care provider, provide evidence of a background check.
State the number of copies of professional licenses that are included here: ________________ State the number of criminalbackground checks that are included here: ________________
5b, continued:
Name ____________________________________________________________________________________
Indicate whether a professional license or background check is being provided (check one):
Background check ____________ Professional License _______________________
Name ____________________________________________________________________________________
Indicate whether a professional license or background check is being provided (check one):
Background check ____________ Professional License _______________________
Name ____________________________________________________________________________________
Indicate whether a professional license or background check is being provided (check one):
Background check ____________ Professional License _______________________
Name ____________________________________________________________________________________
Indicate whether a professional license or background check is being provided (check one):
Background check ____________ Professional License _______________________
Name ____________________________________________________________________________________
Indicate whether a professional license or background check is being provided (check one):
Background check ____________ Professional License _______________________
Name ____________________________________________________________________________________
Indicate whether a professional license or background check is being provided (check one):
Background check ____________ Professional License _______________________
Name ____________________________________________________________________________________
Indicate whether a professional license or background check is being provided (check one):
Background check ____________ Professional License _______________________
Name ____________________________________________________________________________________
Indicate whether a professional license or background check is being provided (check one):
THIS PAGE INSERTED AS A REMINDER
TO INSERT HERE ALL BACKGROUND CHECKS AND COPIES OF
PROFESSIONAL LICENSES FOR EVERY INDIVIDUAL LISTED IN 5b
_________
Section 6
SERVICE LOCATION AND HOURS OF OPERATION
Directions:
•
Provide the information below for the service location you intend to enroll or re-enroll in DC Medicaid.
•
Post Office Boxes are
prohibited
6a) Service Location
Address City/State Zip Code
Telephone Number Fax Number WARD/COUNTY
Email Address
6b) Hours of Operation
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
6c) Does this location have 24-hour 6d) Is this location accessible to public 6e) Does this location meet the access Telephone coverage? Yes ___ No ___ Transportation? Yes ___ No ___ requirements of the Americans with Disabilities Act?
Phone: ( ) __________________
Yes ______ No _____
6f) Does the location have TDD? ___ Yes ____ No TDD Telephone Number ___________________________
o
o
o
Section 7
MAILING ADDRESS FOR PAYMENT OR REMITTANCES
Directions:
•
Provide the address to which you want payments sent. A Post Office Box is acceptable.
•
Provide the address to which you want Remittance Advices sent. A Post Office Box is acceptable.
•
Only one Remittance Address is allowed per provider number.
•
Check whether you will use electronic or paper billing.
7a) Address to which payment should be sent:
_______________________________________________________________________________________________
Address City/State ZIP Code
7b) Address to which Remittances should be sent:
______________________________________________________________________________________________
Address City/State ZIP Code
(if difference from Pay to Address)
______________________________________________________________________________________________________________
Section 8 MAILING ADDRESS FOR CORRESPONDENCE OTHER THAN
PAYMENT OR REMITTANCES
Directions:
•
Provide the mailing address to which correspondence (manual updates, memoranda, etc.) should be sent. A
Post Office Box address is acceptable.
•
Only one Correspondence Address is allowed per enrollment application and provider number.
Address to which correspondence should be sent:
Address City/State ZIP Code
COLUMN I
PRODUCTS TO BE
FURNISHED BY PROVIDER
COLUMN II
QUALIFICATIONS TO PROVIDE SPECIFIC PRODUCTS
Diabetic Footwear
Fitters of therapeutic shoes (non-custom therapeutic shoes and diabetic multi-density inserts)
ABC Certified Fitter credential (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.)
BOC-Certified Orthotic Fitter (COF)
Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s)
Specify ____________________________________________________________________________________
Orthotics Devices– Custom-Fabricated
Orthotic Devices (Custom-Fabricated)
ABC Certified Practitioner (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.)
ABC Registered Orthotic Technician (RTO) for individuals who under the direct supervision of an ABC certified practitioner
administers orthotic services and products. (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.)
BOC-Certified Orthotic (BOCO) (Board for Orthotic/Prosthetic Certification)
Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s)
Specify _____________________________________________________________________________________
Fitters of orthotics, products and services; or therapeutic shoes (non-custom therapeutic shoes and diabetic multi-density inserts)
ABC Certified Fitter credential (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.)
BOC-Certified Orthotic Fitter (COF)
Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s)
Specify _____________________________________________________________________________________
Pedorthic Devices
Therapeutic Shoes - Customized
Shoe Modifications
Foot Orthoses
Pedorthic devices (therapeutic shoes, shoe modifications, & foot orthoses)
ABC Certified Pedorthist (C.Ped) (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.)
BOC Pedorthist Certification (Board for Orthotic/Prosthetic Certification)
Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s)
Specify ______________________________________________________________________________________
Section 9
PRODUCTS AND SERVICES TO BE FURNISHED BY PROVIDER
Directions:
• Complete the chart by placing a check
(√)
in the box next to the specific products (listed in Column I) that your business will deliver to DC Medicaid
recipients. In Column II, check the specific licensure and/or certification held by those persons who will deliver the products and services. If a specific
licensure and/or certification that you hold is not listed below, write or type the name of the licensure, certification or other credential in the space
provided in Column II for “Other.” If a product that you intend to deliver is not listed in the chart below, write or type the name of the product in the
space provided at the end of Column I.
PRODUCTS TO BE
FURNISHED BY PROVIDER
(Continued)
QUALIFICATIONS TO PROVIDE SPECIFIC PRODUCTS
(Continued)
Power Wheelchairs
Customized Manual Wheelchairs and Complex Rehabilitative Wheelchairs & Assistive Technology
RESNA Certified Rehabilitative Technology Supplier (CRTS), with a Rehabilitation Engineering Technologist (RET) credential
RESNA Certified Rehabilitative Technology Supplier (CRTS), with a Assistive Technology Supplier (ATS) credential
RESNA Certified Rehabilitative Technology Supplier (CRTS), with an Assistive Technology Practitioner (ATP) credential
Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s)
Specify _______________________________________________________________________________________
Prosthetics
General * (i.e. non-customized
therapeutic shoes)
Specialty (i.e. Speech Generating
Devices, Voice Prosthetics
Mastectomy
Prosthetic Devices
ABC Certified Practitioner (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.)
ABC Registered Prosthetic Technician (RTP) for individuals who under the direct supervision of an ABC certified practitioner
administers orthotic/prosthetic service and products. (American Board for Certification in Orthotics, Prosthetics and Pedorthics,
Inc.)
BOC-Certified Prosthetic (BOCP) (Board for Orthotic/Prosthetic Certification)
Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s)
Specify _________________________________________________________________________________________
Fitters of mastectomy prostheses, products and services; or therapeutic shoes (non-custom therapeutic shoes and diabetic
multi-density inserts)
ABC Certified Fitter credential (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.)
BOC-Certified Orthotic Fitter (COF) and/or BOC-Certified Mastectomy Fitter (CMF)
Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s):
Specify _____________________________________________________________________________________________
Respiratory Equipment
Bi-level Positive Airway Pressure
Continuous Positive Airway
Pressure
Intermittent Positive Pressure
Respiratory Assist Devices
Respiratory Equipment, Supplies, and Services
Registered Respiratory Therapist (RRT)
Certified Respiratory Therapist (CRT)
Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s):
Specify ___________________________________________________________________________________________
Wheelchairs – Manual (Customized)
Customized Manual Wheelchairs, Power Mobility Devices and Complex Rehabilitative Wheelchairs & Assistive Technology
RESNA Certified Rehabilitative Technology Supplier (CRTS), with a Rehabilitation Engineering Technologist (RET) credential
RESNA Certified Rehabilitative Technology Supplier (CRTS), with a Assistive Technology Supplier (ATS) credential
RESNA Certified Rehabilitative Technology Supplier (CRTS), with an Assistive Technology Practitioner (ATP) credential
Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s):
PRODUCTS TO BE
FURNISHED BY PROVIDER
(Continued)
QUALIFICATIONS TO PROVIDE SPECIFIC PRODUCTS
(Continued)
Additional DME/POS
Apnea Monitor
Commodes
Diabetic Equipment and Supplies
Blood Glucose Monitors
Dialysis Equipment and Supplies
Heat/Cold Applications
Hemodialysis Equipment and Supplies
Hospital Beds
Accessories
Electric
Manual
Lymphoedema Pumps
Mobile Assistive Equipment
Walkers, Canes and Crutches
Patient Lifts and Seat Lift Mechanisms
Orthotics Devices– Non-customized
Oxygen
Oxygen equipment
Concentrators
Reservoirs
High-pressure cylinders
Accessories & Supplies
Conserving Devices
Wound Care Supplies
Applicable licensure, certification and/or training.
PRODUCTS TO BE
FURNISHED BY PROVIDER
(Continued)
QUALIFICATIONS TO PROVIDE SPECIFIC PRODUCTS
(Continued)
Section 10
QUALIFICATIONS OF THE DME/POS BUSINESS
Directions:
• Check [√] agencies where any accreditation is held by your DME/POS business.
• ATTACH PROOF OF ACCREDITATION
BEHIND THIS PAGE.
The Joint Commission (JC)
National Association of Boards of Pharmacy (NABP) Board of Orthotist/Prosthetist Certification (BOC) Community Health Accreditation Program (CHAP) The Compliance Team, Inc.
American Board of Certification in Orthotics & Prosthetics, Inc. (ABC)
The National Board of Accreditation for Orthotic Suppliers (NBAOS)
Commission on Accreditation of Rehabilitation Facilities (CARF)
HealthCare Quality Association on Accreditation (HAQAA) Accreditation Commission for Health Care, Inc. (ACHC)
Section 11
BUSINESS INFORMATION
Directions:
11a) -11i) Check ‘Yes’ or ‘No’ in response to the questions listed.
11j) If ‘Yes’ is checked for #2, provide the name and telephone number of the person who
holds ownership of the warehouse, along with the owner’s complete address.
11k – 11o) Check ‘Yes’ or ‘No’ in response to the questions listed.
11p – 11r) Check ‘Yes’ or ‘No’ in response to the questions listed. If ‘Yes’ is checked, please
explain in the space provided in Section 12.
11s)
Check ‘Yes’ or ‘No’ in response to the questions listed. If ‘Yes’ is checked provide
the information requested in the space provided in Section 12.
11a) Do you have the retail business open and available to the general public, and which meets all local laws and ordinances regarding business licensing and operations and is readily identifiable as a place in which you sell, rent, or lease durable medical equipment, prosthetics, incontinence
medical supplies, and/or medical supply items? Yes __ No __
11b) Do you have a visible sign and posted hours of operation? Yes __ No __ 11c) Do you have inventory or contracts with other companies to ensure the ability to fill orders? Yes __ No __ 11d) Do you advise customers that they may either rent or purchase DME/POS? Yes __ No __ 11e) Do you honor all warranties expressed and implied under State law? Yes __ No __ 11f) Do you have a written complaint resolution process? Yes __ No __ 11g) Will records be stored at the service location? Records must be maintained for 10 years
If not, where are they stored? Provide Address:
_______________________________________________________________________________ Address: City/State Zip Code
Yes __ No __
11h) Do you own the building in which your business is located? Yes __ No __ 11i) Do you lease the building in which your business is located? Yes __ No __ 11j) Is your equipment and/or supplies:
#1) In stock on the premise, and/or
#2) In a warehouse under the applicant’s or provider’s direct control (if checked provide the following information for the warehouse):
Yes __ No __ Yes __ No __
Name of Person who holds ownership in the warehouse:
________________________________________________________________ Address: City/State Zip Code ________________________________________________________________
Telephone Number: ________________________
11k) Do you have the necessary equipment, office supplies, and facilities available to carry out your business, including storing and retrieving such records as are necessary to fully disclose the type and extent of services provided to Medicaid customers?
Yes __ No __
11l) Does you business involve the trade, sale, rental, or transfer of upholstered - furniture (including wheelchairs) or bedding?
Yes __ No __
11m) Does your business involve the trade, sale, rental or transfer of medical devices or durable
medical equipment/devices for use in the home to treat acute or chronic illness of injuries? Yes __ No __
If Yes, does the applicant/provider have on staff, either as an employee or independent contractor, or does the applicant/provider have a contractual relationship with a qualified rehabilitation professional who was directly involved in determining the specific custom
rehabilitation equipment needs of the patient and was directly involved with, or closely, supervised, the final fitting and delivery of the custom rehabilitation equipment?
Yes __ No __
11p) Has any officer and/or employee of the business ever been convicted of a felony?
11q) Has the applicant/provider ever been rejected or suspended from the Medicare or Medicaid program, or has your participation status ever been modified (terminated, suspended, restricted, revoked, limited, cancelled or sanctioned)?
Yes __ No __ If Yes, please explain in
Section 12
Yes __ No __ If Yes, please explain in
Section 12 11r) Within the last five (5) years, has the applicant/provider ever been sanctioned, reprimanded or
otherwise disciplined in any manner by any state licensing authority or other professional board or peer committee?
Yes __ No __ If Yes, please explain in
Section 12 11s) Does applicant/provider own, have an investment in, manage, own stock in, participate in a
joint venture, or act as a partner, contract consultant or medical/dental advisor in any medical/dental enterprise or medical/dental supplier outside of the business identified in this application where you would financially benefit directly or indirectly?
Yes __ No __ If Yes, please explain in
Section 12
DETAILED EXPLANATIONS FOR SECTION 10 QUESTIONS
Directions: If you answered “YES” to questions “11p”, “11q”, “11r” and “11s”, please provider an explanation or additional
information for each.
QUESTION 11p ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ QUESTION 11q ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ QUESTION 11r ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ QUESTION 11s
Name of Organization _____________________________________________________Type of Organization __________________ Mailing Address
___________________________________________________________________________________________________________
Telephone Number _______________________________ Tax ID Number _______________________
Percent of Business Owned/Invested by You ___________
Section 13
DISCLOSURE OF OWNERSHIP
Directions: Follow the instructions found in this section to complete the document on the next page. Remember to sign the
document.
INSTRUCTION FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT (DC-1513)
Completion and submission of this form is a condition of participation, certification, or recertification under any of the programs established by Titles V, XVIII, XIX, AND XX, or as a condition of approval or renewal of a contractor agreement between the disclosing entity and the District of Columbia state agency under any of the above-titled programs, a full and accurate disclosure of ownership and financial interest is required. Failure to submit requested information may result in a refusal by the D.C. State Agency to enter into an agreement or contract with any such institution or in termination of existing agreements.
SPECIAL INSTRUCTIONS FOR TITLE XX PROVIDERS
All title XX providers must complete Part II (a) and (b) of this form. Only those Title XX providers rendering medical, remedial, or health related homemaker services must complete Parts II and III. Title V providers must complete Parts II and III.
General Instructions
For definitions, procedures and requirements refer to the appropriate Regulations:
Title V -42CFR 51a.144
Title XVIII -42CFR 420.200-206
Title XIX -42CFR 455.100-106 Title XX -45CFR 228.72-73
Please answer all questions as of the current date. If the yes block for any item is checked, list requested additional information under the Remarks Section on page 2, referencing the item number to be continued. If additional space is needed use an attached sheet. Return the original copy to the State agency: retain the photocopy for your files.
DETAILED INSTRUCTIONS
These instructions are designed to clarify certain questions on the from. Instructions are listed in question order for easy reference. No instructions have been given for questions considered self-explanatory. IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL INFORMATION BE CURRENT.
Item I – Under identifying information specify in what capacity the entity is doing business as (DBA), example, name of trade or corporation.
Item II- Self-explanatory
Item III- List the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination amounting to an ownership interest of 5 percent or more in the disclosing entity.
Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity. A disclosing entity is defined as a Medicare provider or supplier, or other entity that furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health program, or health related services under the social services program.
Indirect ownership interest is defined, as ownership interest in an entity that has direct or indirect ownership interest in the disclosing entity .The amount of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership interest must be reported if it equates to an ownership interest of 5 percent or more in the disclosing entity. Example: if A owns 10 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing entity, A’s interest equates to an 8 percent indirect ownership and must be reported.
Controlling interest is defined as the operational direction or
management of a disclosing entity, which may be maintained, by any or all of the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity (i.e. joint venture
agreement, unincorporated business status) of the disclosing entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of the disclosing entity; the ability or authority, expressed or reserved, to amend or change the by-laws, constitution, or other operating or management direction of the disclosing entity; the right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity, or to arrange for the sale or transfer of the disclosing entity to new ownership or control.
Items IV-VII- Changes in Provider Status
Change in provider status is defined as any change in management control. Examples of such changes would include: a change in Medical or Nursing Director, a new Administrator, contracting the operation of the facility to a management corporation, a change in the composition of the ownership partnership which under applicable State law is not considered a change in ownership, or the hiring or dismissing of any employees with 5 percent or more financial interest in the facility or in an owning corporation or any change of ownership.
For Items IV-VII, if the yes box is checked, list additional information requested under Remarks. Clearly identify which item is being continued.
Item IV- (a & b) If there has been a change in ownership within the last year or if you anticipate a change, indicate that date in the appropriate space.
Item V- If the answer is yes, list name of the management firm and employer identification number (EIN), or the name of the leasing organization. A management company is defined as any organization that operates and manages a business on behalf of the owner of that business, with the owner retaining ultimate legal responsibility for operation of the facility.
Item VI- If the answer is yes, identify which has changed
(Administrator, Medical Director, or Director of Nursing) and the date the change was made. Be sure to include name of the new
Administrator, Director of Nursing or Medical Director, as appropriate.
Item VII- A chain affiliate is any free-standing health care facility that is either owned, controlled, or operated under lease or contract by an organization consisting of two or more free-standing health care facilities organized within or across State lines which is under the ownership or through any other device, control and direction of a common party. Chain affiliates include such facilities whether public, private, charitable or proprietary. They also include subsidiary organizations and holding corporations. Provider-based facilities, such as hospital-based home health agencies, are not considered to be chain affiliates.
Item VIII -If yes, list the actual number of beds in the facility now and the previous number
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
Identifying Information
(a). Name of Entity D/B/A Medicaid Provider No. NPI Number.
Identifying Information
(a). Name of Entity D/B/A Medicaid Provider No. NPI Number.
Telephone No.
Telephone No.
Street Address City, County, State Zip Code
II. Answer the following questions by checking “Yes” or “No”. If any of the questions are answered “Yes”, list names and addresses of individuals or
corporations under Remarks on page 2. Identify each item number to be continued.
A. Are there any individuals or organizations having a direct or indirect ownership or control interest of 5 percent or more in the institution,
organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons, or organizations in any
of the programs established by Titles XVII, XIX, or XX?
Yes No
B. Are there any directors, officers, agents, or managing employees of the institution, agency or organization who have ever been convicted of
a criminal offense related to their involvement in such programs established by Titles XVII, XIX, or XX?
Yes No
C. Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar
capacity who were employed by the institution’s organization’s, or agency’s fiscal intermediary or carrier within the previous 12 months?
(Title XVII providers only)
Yes No
III. (a.) List names, addresses for individuals, or the EIN for organization having direct or indirect ownership or a controlling interest in the entity.
(See instructions for definition of ownership and controlling interest.) List any additional names and addresses under “Remarks” on Page 2.
If more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks.
Name Address EIN
(b) Type of Entity:
Sole Proprietorship
Partnership
Corporation
Unincorporated Associations
Other (Specify)
(c) If the disclosing entity is a corporation, list names, addresses of the Directors, and EINs for corporations under Remarks.
Check appropriate box for each of the following questions
(d) Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities? (Example, sole proprietor, partnership or members of
Board of Directors.) If yes, list names, addresses of individuals and provider numbers.
Yes No
IV.
(a). Has there been a change in ownership or control within the last year?
Yes No
If yes, give date ____________________
(b) Do you anticipate any change of ownership or control within the year?
Yes No
If yes, when? ______________________
(c) Do you anticipate filing for bankruptcy within the year?
Yes No
If yes, when ______________________
(d)Is this facility operated by a management company, or leased in whole or part by another organization?
Yes No
If yes, give date of change in operations _______________________________
V. (a) Is this facility chain affiliated? (If yes, list name, address of Corporation, and EIN)
Yes No
Name
EIN#
Address
WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR
REPRESENTATION OF THIS STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN
ADDITION, KNOWINGLY AND WILLFULY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION
REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY
PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE D. C. STATE AGENCY AS
APPROPRIATE.
Name of Authorized Representative Title
Section
14
REQUEST
FOR
TAXPAYER
IDENTIFICATION NUMBER AND CERTIFICATION
Section 15
AUTHORIZATION TO RELEASE INFORMATION
Directions: Review this document carefully. Sign and date it.
I authorize the District of Columbia Medical Assistance Administration, hereafter “agency” and its affiliates, subsidiaries or related entities to consult with hospital administrators, members of medical staffs of hospitals, malpractice carriers, licensing boards, professional organizations, and other persons to obtain and verify information and I release to the agency and its employees and agents from any and all liability for their acts performed in good faith and without malice in obtaining and verifying such information and in evaluating my application; and,
I consent to the release by any person to the agency of all information that may be reasonably relevant to an evaluation of my professional competency, character, and moral and ethical qualification, including any information relating to any disciplinary action, suspension or limitation of privileges, and hereby release any such person providing such information from any and all liability for doing so.
This credentialing information and the attached documents contain detailed and specific information relating to my character and professional competence. I warrant that all of the information that I have provided and the responses that I have given are correct and complete to the best of my knowledge and belief. I understand that willful falsification or willful omission of this information will be grounds for rejection or termination.
I further agree to notify the agency of any change to the information provided in this application within thirty (30) days of any such change. I understand that any information provided in this application that is not publicly available will be treated as confidential by the carrier.
______________________________________________ __________________________
Signature of Authorized Applicant/Provider Date
______________________________________________ __________________________
Printed Name of Authorized Applicant/Provider Telephone Number
______________________________________________ __________________________
