List officers’ and board members’ information of disclosing entity. The entire first name is required. Initials are not accepted.

Subcontractor – means 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 Medicaid agreement.

If the question is not applicable, click on the Checkbox

If fields are populated and then “N/A Checkbox” is selected, all data entered will be cleared

If the question is applicable, complete all of the fields

Name

• Please enter the officer or board member’s first and last name.  Initials are not accepted in this field

Title

• Please select title from the dropdown box

• (Insert link to Table 1)

SSN

• Social Security Number is not a required field, but is highly recommended to expedite the processing of this application

• In some instances, the Social Security Number is required and the application shall notify the application why the SSN is required

Address

• Enter all of the required fields for the address

• The state will automatically default to Kentucky, but is editable by selecting another state from the dropdown box

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