List the name of any other disclosing entity in which an owner of the disclosing entity has an ownership or control interest.
Overview: If any other disclosing entity in which an owner of the disclosing entity has an ownership or control interest, provide the following information
Company Name
Enter the Company Name
Must be a company name, not an individual name
Provider Number
Enter the Provider Number
This can be a Medicaid or Medicare Provider Number from any state
Address
Enter the address information in this field
City
Enter the appropriate city for the applicable address
State
State defaults to Kentucky but is editable
Select the appropriate state from the drop down box
Zip Code
Enter the appropriate zip code for the applicable address entered
Zip+4
If known, enter the appropriate +4 Zip code
For applicants enrolling under Individual Category, the system shall default value to N/A and the user will not be able to modify any fields on this screen. They may click “Exit,” “Back,” or “Save & Next”
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