List name, address, SSN, FEIN, of each person with an ownership or control interest in any SUBCONTRACTOR in which the provider applicant has direct or indirect ownership of 5% or more.

Subcontractor – indicates an individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients, OR an individual, agency or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or lease of real property) to obtain space, supplies, equipment or services provided under the Medical agreement.

Disclosing Entity – The entity that is requesting Medicaid enrollment.

Ownership Interest – indicates an ownership interest in an entity that has an ownership interest in the disclosing entity.  This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.  

Indirect Ownership Interest – indicates the possession of equity in the capital, the stock, or the profits of the disclosing entity.

Person with an ownership or control interest – indicates a person or corporation that:

• Has an ownership interest totaling 5% or more in a disclosing entity;

• Has an indirect ownership interest equal to 5% or more in a disclosing entity; has a combination of direct and indirect ownership interests equal to 5% or more in a disclosing entity.

• Has a combination of direct and indirect ownership interests equal to 5% or more in a disclosing entity;

• Owns an interest of 5% or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5% of the value of the property or assets of the disclosing entity.

• Is an officer or director of a disclosing entity that is organized as a corporation; or,

• Is a partner in a disclosing entity that is organized as a partnership

Name

• Enter the First and Last Name.  Middle Initials are optional in this field.

• Upon First and Last Names (Middle Name if entered, as well) being added to the grid as a record, the first, middle, and last names will display in the grid as Name in following format:  Last Name, First Name  Middle Name (if entered), ex  Kennedy, John Fitzgerald

SSN

• Enter the Social Security Number

Business Name

• Business name or FEIN is required

FEIN

• Federal Employer Identification Number (FEIN) or Business Name is required

Address

• Enter the address information in this field

City

• Enter the city for the applicable address

State

• State defaults to Kentucky but is editable

• Select the state from the drop down box

Zip Code

• Enter the zip code for the applicable address entered

Zip+4

• If known, enter the +4 Zip code

If fields are entered then N/A is checked, the data entered will be cleared

Special Characters:

• The following Special Characters cannot be used in the situations below. Field properties will not allow the following characters in the box:

 For First Name, Business Name, Other name (if any):    | + \ '

 For Last Name field:    | + \ ', and numbers are not allowed

 For Comment Boxes:     <  >  ^  ~ ` + | \ / ¬ £

 For Address fields:    | + ! @ # $ ^ * ( ) ? / \ " < > & : ; _

• If you copy and paste an excluded special character, an error message will display after clicking Save & Next

• Remove excluded characters from pasted information or uploaded text in the document

Save & Next:

• When finished, click Save & Next to save the information and proceed to the next page

• Click Back to go to the previous screen without saving

• Click Exit to return to the dashboard without saving

• Note that if the information is not saved, you will lose the data on the current page