If this facility is a subsidiary of a parent corporation, enter corporate FEIN:

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

If a corporate entity is disclosed in question #6, the business locations of the corporate entity must be disclosed.

• Select the checkbox to upload the business location document later in the Document Upload section.

• Click on the hyperlink on the screen to download the business location template or enter the location information in the appropriate fields.

Entity Name

• Enter the entity name

Address

• Enter the physical address. PO boxes are not permitted.

City

• Enter the City

State

• Select the state from the drop down box.

Zip Code

• Enter the zip code

Zip+4

• Enter the zip+4.  This is not a required field and can be left blank if unknown.  This will be auto populated during validation process

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Once all of the data entry fields are complete for each location, click the “Add To Grid” button to populate the new information in the grid

Clicking the “Remove” hyperlink in the Grid will remove selected data

Clicking the “Edit” hyperlink in the Grid will direct the applicant to data entry fields for corrections

End Date:

In KY MPPA, some records cannot be deleted. To add a new record, the previous record must have an End Date added in order to keep the history on file. To add an End Date to a record, click the "Edit" button and add an End Date. If a new record is added to the grid, the active dates of the new record cannot overlap existing record dates.

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