List the name of any individuals or organizations having direct or indirect ownership or controlling interest of 5% or more, who has been convicted of a criminal offense related to the involvement of such persons, or organizations in any program established under Title XVIII (Medicare), or Title XIX (Medicaid), of Title XX (Social Services Block Grants) of the Social Security Act or any criminal offense in this state or any other state, since the inception of those programs.  

If individual or organization is associated with a KY Medicaid provider number(s), please indicate below.

Indirect 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.

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;

• 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 there are any individuals or organizations having direct or indirect ownership or controlling interest of 5% or more, who has been convicted of a criminal offense related to the involvement of such persons, or organizations in any program established under Title XVIII (Medicare), or Title XIX (Medicaid), of Title XX (Social Services Block Grants) of the Social Security Act or any criminal offense in this state or any other state, since the inception of those programs, indicate below. Also, if an individual or organization is associated with a KY Medicaid provider number(s), please indicate below.

Name

• Enter the First and Last Name.  Initials are not accepted in this field

OR

Provider Business Name

• Enter the Provider Business Name

•  

KY Medicaid Provider Number

• Enter the Provider’s KY Medicaid ID number

• This is not a mandatory field

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