If you completed question #1, describe the relationship between the corporate boards of disclosing provider and previous corporate boards of Medicaid provider.

Relationship

• Utilize the space provided to describe the relationship between the corporate boards of the disclosing provider on this form and previous corporate boards of the Medicaid provider

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